The effect of the native kinematics of the knee on the outcome following total knee arthroplasty.

AIMS: The aim of this study was to investigate differences in pain, range of movement function and satisfaction at three months and one year after total knee arthroplasty (TKA) in patients with an oblique pattern of kinematic graph of the knee and those with a varus pattern. PATIENTS AND METHODS: A total of 91 patients who underwent TKA were included in this retrospective study. Patients (59 women and 32 men with mean age of 68.7 years; 38.6 to 88.4) were grouped according to kinematic graphs which were generated during navigated TKA and the outcomes between the groups were compared. RESULTS: The graphs were varus in 50 patients (55%), oblique in 19 (21%), neutral in 17 (18.5%) and valgus in five (5.5%). After adjustment for pre-operative scores and gender, compared with patients with varus knee kinematics, patients with an oblique kinematic graph had a poorer outcome with lower Knee Society scores at three months (9.2 points, p = 0.038). CONCLUSION: We found four distinct kinematic graphs in knees and that patients with an oblique graph have a poorer outcome in the short-term after TKA. Cite this article: Bone Joint J 2016;98-B:1471-8.

Influence of a regional centralised upper gastrointestinal cancer service model on patient safety, quality of care and survival.

AIMS: The aim of this study was to determine outcomes of a reconfigured centralised upper gastrointestinal (UGI) cancer service model, allied to an enhanced recovery programme, when compared with historical controls in a UK cancer network. MATERIALS AND METHODS: Details of 606 consecutive patients diagnosed with UGI cancer were collected prospectively and outcomes before (n = 251) and after (n = 355) centralisation compared. Primary outcome measures were rates of curative treatment intent, operative morbidity, length of hospital stay and survival. RESULTS: The rate of curative treatment intent increased from 21 to 36% after centralisation (P < 0.0001). Operative morbidity (mortality) and length of hospital stay before and after centralisation were 40% (2.5%) and 16 days, compared with 45% (2.4%) and 13 days, respectively (P = 0.024). The median and 1 year survival (all patients) improved from 8.7 months and 39.0% to 10.8 months and 46.8%, respectively, after centralisation (P = 0.032). On multivariate analysis, age (hazard ratio 1.894, 95% confidence interval 0.743-4.781, P < 0.0001), centralisation (hazard ratio 0.809, 95% confidence interval 0.668-0.979, P = 0.03) and overall radiological TNM stage (hazard ratio 3.905, 95% confidence interval 1.413-11.270, P < 0.0001) were independently associated with survival. CONCLUSION: These outcomes confirm the patient safety, quality of care and survival improvements achievable by compliance with National Health Service Improving Outcomes Guidance.

Single incision laparoscopic adjustable gastric band: technique, feasibility, safety and learning curve.

INTRODUCTION: Single incision laparoscopic surgery (SILS) is established in many procedures but not in bariatric surgery. One explanation may be that SILS is technically demanding in morbidly obese patients. This report describes our technique and experience with single incision laparoscopic adjustable gastric banding (SILAGB). METHODS: Prospective data collection was performed on consecutive obese patients who underwent SILAGB between November 2009 and February 2011. A single 3 cm transverse incision in the right upper quadrant was used for a Covidien SILS™ multichannel access port. The technique is described with a standard pars flaccida approach and the 'tips and tricks' needed for a wide range of candidates using standard laparoscopic equipment. RESULTS: A total of 29 patients (27 female) with a median body mass index of 41 kg/m(2) (range: 35-52 kg/m(2)) and median age of 44 years (range: 22-57 years) underwent SILAGB. There were no 'conversions' to a standard laparoscopic technique. Two cases required the addition of one single 5 mm port. The only complications were two postoperative wound infections (one with a port site infection requiring replacement of the port) and one faulty band requiring replacement. There were therefore two returns to theatre and no 30-day deaths. All patients were discharged on the first postoperative day. In this series, operative times reduced significantly to be comparable with the conventional laparoscopic approach. CONCLUSIONS: SILAGB is safe and feasible in the morbidly obese. Proficiency in this technique using conventional laparoscopic equipment can be achieved with a short learning curve.

Maximizing profit on New England organic dairy farms: an economic comparison of 4 total mixed rations for organic Holsteins and Jerseys.

The objective of these experiments was to compare 4 total mixed rations fed to USDA-certified organic dairy cows in New England. Forty-eight Jersey cows from the University of New Hampshire (UNH) and 64 Holstein cows from the University of Maine (UMaine) were assigned to a 2 × 2 factorial arrangement of treatments testing the main effects of corn silage versus grass silage as the forage base and commodity concentrates versus a complete pelleted concentrate mixture. Treatment diets were fed as a total mixed ration for 8 wk during the winter and spring months of 2007, 2008, and 2009. Milk yield, component, and quality data were recorded and used to calculate the value of the milk produced for each cow. The dry matter intake (DMI) was recorded and used to calculate the average cost per cow per day of each diet. Income over feed costs were calculated for each diet using milk value and feed cost data. Feed cost and income over feed cost data were resampled using bootstrap methodology to examine potential patterns. Milk yield, milk fat and true protein concentrations, and SCC were similar among treatments. Cows at UNH fed corn silage tended to have higher DMI and lower milk urea nitrogen than did cows fed grass silage, whereas cows fed pellets had higher DMI than cows fed commodities. Cows at UNH fed commodities tended to have higher body condition scores than those fed pellets. Cows at UMaine fed commodities tended to have higher DMI than did cows fed pellets, and cows fed corn silage had lower milk urea nitrogen than did cows fed grass silage. Body weights and body condition scores were not different for cows at UMaine. Feed costs were significantly higher for corn silage diets and diets at UNH containing pellets, but not at UMaine. The calculated value of the milk and income over feed costs did not differ among treatments at either university. Bootstrap replications indicated that the corn silage with commodities diet generally had the highest feed cost at both UNH and UMaine, whereas grass silage diets containing commodities generally had the lowest cost. In contrast, the grass silage with commodities diets had the highest income over feed cost in the majority of the replications at both UNH and UMaine replications, whereas the corn silage with commodities diets had the lowest rank. Similar results were observed when forage prices were increased or decreased by 5, 10, and 25% above or below the actual feed price. Feeding a grass silage-based diet supplemented with commodity concentrates may have an economic advantage for dairy producers in New England operating under an organic system of production.

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network.

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10-year period (median age 61 [31-79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2-year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02-1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16-9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long-term survival was unaffected.

Stage-for-stage comparison of definitive chemoradiotherapy, surgery alone and neoadjuvant chemotherapy for oesophageal carcinoma.

BACKGROUND: Definitive chemoradiotherapy (dCRT) has been proposed as an alternative therapy for selected patients with oesophageal cancer. The aim of this study was to determine the outcomes of dCRT, surgery alone, and neoadjuvant chemotherapy followed by surgery (CS) in patients with oesophageal cancer. METHODS: Consecutive patients diagnosed with oesophageal cancer and managed by a multidisciplinary team were staged by computed tomography and endoluminal ultrasonography. Those deemed unsuitable for surgery on the grounds of performance status, bulky local disease or personal choice received dCRT. The primary outcome measure was overall survival measured from date of diagnosis. RESULTS: Of 417 patients, 173 received dCRT, 126 underwent surgery alone and 118 received CS. The incidence of grade III/IV toxicity after dCRT and CS was 39.3 and 60.2 per cent respectively. Operative morbidity rates were 42.9 and 44.4 per cent after surgery alone and CS respectively. Thirty-day mortality rates were zero, 7.9 and 0.8 per cent after dCRT, surgery alone and CS respectively. Overall 2-year survival rates were 44.3, 56.2 and 42.4 per cent (P = 0.422). CONCLUSION: These findings support the need for a randomized trial of dCRT versus CS for resectable oesophageal cancer.

Workload and resource implications of upper gastrointestinal cancer surgical centralisation in South East Wales.

INTRODUCTION: The aim of this study was to determine whether one specialist unit could manage all patients diagnosed with oesophagogastric cancer in Gwent and Cardiff and Vale NHS Trusts over a 6-month period with regard to workload, resource and training opportunities. PATIENTS AND METHODS: All patients diagnosed with oesophagogastric (OG) cancer in Gwent and Cardiff and Vale NHS Trusts and referred to the regional South East Wales Upper GI multidisciplinary team over the 6-month period from 1 July to 31 December 2005 were studied prospectively and compared with the previous 6-month caseload at Cardiff and Vale. RESULTS: Out-patient workload increased from 160 new (33 OG cancers) and 533 follow-up patients (161 OG cancers) between 1 January and 30 June 2005, to 290 new (68 OG cancers, 106% increase) and 865 follow-up patients (230 OG cancers, 43% increase) between 1 July, and 31 December 2005. The number of patients undergoing radical surgery increased from 14 to 23 (D2 gastrectomy 8 versus 13; oesophagectomy 6 versus 10). Cancer-related workload in the latter period generated 118 intermediate equivalents (IEs) of operative work for two specialist surgeons and one SpR occupying 38% of the total time available on 104 scheduled operating lists, compared with 64 IEs in the previous 6 months, representing an 84% increase in cancer-related operative training opportunities. CONCLUSIONS: Centralisation of oesophagogastric cancer surgery is feasible and desirable if national guidelines are to be satisfied, and this strategy has significant positive implications for surgical training and audit.

Prospective cohort comparison of neoadjuvant chemoradiotherapy versus chemotherapy in patients with oesophageal cancer.

BACKGROUND: Chemotherapy and chemoradiotherapy are common neoadjuvant treatments for resectable T3 N0-1 M0 oesophageal carcinoma. The aim of this study was to compare the outcomes of these therapies in consecutive cohorts of patients. METHODS: Between January 1998 and December 2001, 88 patients received neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil (5-FU), prior to 45 Gy in 25 F concurrent radiotherapy with cisplatin and 5-FU). From 2002, 117 patients received neoadjuvant chemotherapy (76 patients had two cycles of cisplatin and 41 had four cycles of epirubicin, cisplatin and 5-FU). The primary outcome measure was survival, and analysis was by intention to treat. RESULTS: Postoperative morbidity and mortality rates were 56 per cent (40 patients) and 10 per cent (seven patients) respectively in the chemoradiotherapy group, compared with 47 per cent (46 patients) and 1 per cent (one patient) in the chemotherapy group (P = 0.008). The cumulative 5-year survival rate by intention to treat was 35 per cent after chemoradiotherapy versus 21 per cent after chemotherapy (P = 0.188). The cumulative corrected 5-year survival rate after completed treatment was 44 per cent for chemoradiotherapy compared with 25 per cent for chemotherapy (P = 0.032). CONCLUSION: Neoadjuvant chemoradiotherapy should remain an option for patients with satisfactory performance status.

Prospective comparison of transthoracic versus transhiatal esophagectomy following neoadjuvant therapy for esophageal cancer.

Transthoracic esophagectomy (TT) has been championed as a better cancer operation than transhiatal esophagectomy (TH) because the approach facilitates meticulous wide tumor excision and lymphadenectomy. However, neoadjuvant chemoradiotherapy (CRTS) and chemotherapy (CS) have been reported to improve outcomes, and we aimed to compare outcomes after multimodal therapy related to the operative approach. One hundred and fifty-one consecutive patients were studied prospectively. All patients were staged with computed tomography and endoluminal ultrasound, and treatment decisions were related to stage and performance status. One hundred and nineteen TT (median age 58 years, 92 male, 54 CRTS, 65 CS) were performed compared to 32 TH (median age 57 year, 27 male, 14 CRTS, 18 CS). Primary outcome measure was survival. Post-operative morbidity and mortality were 54% and 4%, respectively, after TT compared with 59% and 6% after TH (chi2 0.239 df 1, P=0.625). Recurrent cancer was no less frequent after TT (52%) than after TH (37.5%, chi2 2.151 df=1, P=0.142). Cumulative uncorrected 5-year survival was 34% after TT compared with 53% after TH (log rank 1.44, df=1, P=0.2298). Median survival was also similar in lymph node positive patients (TT vs. TH, 23 months vs. 22 months, respectively, log rank 0.25, df=1, P=0.6199). Despite the fact that patients receiving multimodal therapy and a TH esophagectomy were less fit, operative morbidity, mortality and recurrence were similar, and survival did not differ significantly when compared with multimodal TT esophagectomy.

A case of gastric carcinoma and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).

We report a patient in whom the diagnoses of the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and gastric carcinoma were made concurrently. After a gastrectomy, there was resolution of the electrolyte disturbances. This represents the third reported case of this association in the English language literature.

Prognostic significance of body mass indices for patients undergoing esophagectomy for cancer.

The aim of this study was to determine the role of body mass index (BMI) in a Western population on outcomes after esophagectomy for cancer. Two hundred and fifteen consecutive patients undergoing esophagectomy for esophageal cancer of any cell type were studied prospectively. Patients with BMIs > 25 kg/m were classified as overweight and compared with control patients with BMIs below these reference values. Ninety-seven patients (45%) had low or normal BMIs, 86 patients (40%) were overweight, and a further 32 (15%) were obese. High BMIs were associated with a higher incidence of adenocarcinoma versus squamous cell carcinoma (83%vs. 14%, P = 0.041). Operative morbidity and mortality were 53% and 3% in overweight patients compared with 49% (P = 0.489) and 8% (P = 0.123) in control patients. Cumulative survival at 5 years was 27% for overweight patients compared with 38% for control patients (P = 0.6896). In a multivariate analysis, age (hazard ratio [HR] 1.492, 95% CI 1.143-1.948, P = 0.003), T-stage (HR 1.459, 95% CI 1.028-2.071, P = 0.034), N-stage (HR 1.815, 95% CI 1.039-3.172, P = 0.036) and the number of lymph node metastases (HR 1.008, 95% CI 1.023-1.158, P = 0.008), were significantly and independently associated with durations of survival. High BMIs were not associated with increased operative risk, and long-term outcomes were similar after R0 esophagectomy.

Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT Protocol).

A controlled study, comparing computer- and conventional jig-assisted total knee replacement in six cadavers is presented. In order to provide a quantitative assessment of the alignment of the replacements, a CT-based technique which measures seven parameters of alignment has been devised and used. In this a multi-slice CT machine scanned in 2.5 mm slices from the acetabular roof to the dome of the talus with the subject's legs held in a standard position. The mechanical and anatomical axes were identified, from three-dimensional landmarks, in both anteroposterior and lateral planes. The coronal and sagittal alignment of the prosthesis was then measured against the axes. The rotation of the femoral component was measured relative to the transepicondylar axis. The rotation of the tibial component was measured with reference to the posterior tibial condyles and the tibial tuberosity. Coupled femorotibial rotational alignment was assessed by superimposition of the femoral and tibial axial images. The radiation dose was 2.7 mSV. The computer-assisted total knee replacements showed better alignment in rotation and flexion of the femoral component, the posterior slope of the tibial component and in the matching of the femoral and tibial components in rotation. Differences were statistically significant and of a magnitude that support extension of computer assistance to the clinical situation.

Effect of endoscopic ultrasonography on the management of 100 consecutive patients with oesophageal and junctional carcinoma.

BACKGROUND: Endoscopic ultrasonography (EUS) offers very accurate tumour and node staging information for oesophagogastric cancer. The aim was to determine whether the addition of EUS directly influenced the definitive management plan for individual patients. METHODS: Personal and staging information from 100 consecutive patients with carcinoma of the oesophagus or oesophagogastric junction were summarized and blinded. Three consultant oesophagogastric surgeons independently made a management decision for each patient, in the presence and absence of the EUS data. All scored their perceived value of the EUS staging data for each patient. RESULTS: EUS was deemed useful in 63-87 per cent of patients and its addition resulted in an increased number of concordant management plans (from 53 to 62 per cent), and increased agreement between surgeons. The greatest change in concordant management was an increased referral of patients for non-surgical palliation. CONCLUSION: The addition of EUS to the staging of patients with oesophageal and oesophagogastric junction cancer significantly altered the management strategy for some of these patients.

Histological changes in the oesophageal squamous mucosa: correlation with ambulatory 24 hour pH monitoring.

AIMS: To determine the value of squamous mucosal histology in the assessment of patients with gastro-oesophageal reflux symptoms. METHODS: Sixty six patients with reflux symptoms underwent endoscopy with oesophageal biopsy, manometry, and 24 hour oesophageal pH testing. The following histological features were assessed in squamous mucosa: the degree of basal cell hyperplasia, the degree of papillary zone elongation, and the density of neutrophil and eosinophil infiltration. Comparisons were made between the histological findings and the oesophageal function tests. RESULTS: The correlation between the traditionally accepted histological markers of gastro-oesophageal reflux disease in squamous mucosa and 24 hour pH testing was predominantly negative, with the exception of neutrophil inflammation in the squamous mucosa of patients with complicated reflux disease. CONCLUSIONS: This study was unable to confirm the value of the Ismail-Beigi criteria as histological markers of acid reflux. By inference, biopsy of the oesophageal squamous mucosa is of limited value in the assessment of patients with reflux symptoms.

Combined laparoscopic/endoscopic anvil placement for the performance of the gastroenterostomy.

BACKGROUND: We developed the laparoscopic gastric bypass in 1993 and first reported the technique and results in 1994. The technique for the gastroenterostomy was derived from the method used in the percutaneous endoscopic gastrostomy tube placement. Some have questioned the safety of this technique, and alternatives have been proposed. METHOD: Prospectively, we have followed and recorded the results of our laparoscopic patients. To date we have performed over 1,400 laparoscopic gastric bypass operations using the same technique of anvil placement: pulling the anvil down from the mouth to the stomach pouch with a percutaneously placed wire. All patients underwent upper GI endoscopy following the anvil placement, and a water-soluble upper GI series was obtained on the first postoperative day. RESULTS: There have been no esophageal injuries in the first 1400 patients on whom this technique was done. CONCLUSION: The percutaneous pull-wire technique is a safe and effective method to place the 21-mm circular stapler anvil for the performance of a laparoscopic gastroenterostomy.

Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up.

BACKGROUND: The authors have performed the laparoscopic gastric bypass since 1993 and perform about one-half of bariatric cases laparoscopically. Since our initial report, several groups throughout the world have preformed the gastric bypass laparoscopically, with various modifications. METHOD: Prospectively, we followed and recorded the results of our laparoscopic patients. A detailed pre- and post-operative analysis of the patient's co-morbidities is performed as well as complete weight and laboratory data evaluation. RESULTS: With > 80% follow-up, we found an excess weight loss of about 80% by the first year. This degree of loss is well sustained. Over 95% of the significant pre-operative co-morbidities are controlled. CONCLUSION: The laparoscopic gastric bypass has been refined over 5 years of use. Though we have not changed the basic operation as we originally described, others have modified the various anastomotic techniques. The weight loss results are very good to excellent, with patients now out to "long-term" follow-up. Resolution of the co-morbidities is documented. The operation has an adequate track record to show effectiveness, and training programs should be established to maximize safety.

Patterns of gastritis in patients with gastro-oesophageal reflux disease.

BACKGROUND: The cause of inflammation in cardiac mucosa at the gastro-oesophageal junction (GOJ) is unclear, both gastro-oesophageal reflux disease (GORD) and Helicobacter pylori having been implicated. AIMS: To describe patterns of gastritis in patients with symptomatic GORD. METHODS: In 150 patients (126 normally located Z-line, 24 Barrett's oesophagus) with symptoms of GORD, biopsies were taken of the GOJ, corpus, and antrum. Inflammation was assessed using the updated Sydney System. RESULTS: For the 126 patients with a normally located Z-line, biopsies of the GOJ revealed cardiac mucosa in 96, fundic mucosa in 29, and squamous mucosa in one. Inflammation in glandular mucosa at the GOJ was present in 99/125 specimens (79%), including 87/96 (91%) with cardiac mucosa and 12/29 (41%) with fundic mucosa. Inflammation in fundic mucosa was closely related to H pylori and active inflammation was only seen in its presence. Inflammation in cardiac mucosa was less closely linked to H pylori. When H pylori was present in cardiac mucosa (28/96, 29%) active inflammation was usually present (25/28, 89%). However, active inflammation was also found in 34/68 (50%) cardiac mucosa specimens without H pylori. Overall, 28/87 (32%) biopsies with carditis were colonised with H pylori and 59/87 (68%) were not. In H pylori colonised patients, inflammation was seen throughout the stomach, while in non-colonised patients, it was confined to cardiac mucosa. CONCLUSIONS: Patients with symptomatic GORD had a high prevalence of carditis. This was of two types, H pylori associated and unassociated. Except on Giemsa staining, the two were morphologically identical, suggesting mediation by a similar immunological mechanism.

Serial endoscopic ultrasound in the assessment of response to chemoradiotherapy for carcinoma of the esophagus.

The aim of the study was to assess whether endoscopic ultrasound (EUS) could accurately measure the locoregional response to chemoradiotherapy in patients with carcinoma of the esophagus. Seventeen patients with esophageal carcinoma underwent EUS examination before and on completion of chemoradiotherapy. The EUS findings were correlated with the results of histologic examination of the esophagectomy specimen. The accuracy of EUS in these patients was compared with the accuracy of EUS in a control group of 17 patients treated by surgery alone. In 16 of 17 patients EUS-determined tumor (T) stage was unchanged following treatment and in one patient there was T-stage progression. No patient demonstrated downstaging of the primary tumor according to classical EUS criteria. In 10 of 17 patients a reduction in maximum tumor depth of >/=2 mm was observed (range 2 to 18 mm). Histologic examination revealed that four patients with squamous cell carcinoma had experienced a complete pathologic response. These four patients had significantly lower posttreatment EUS tumor depths compared to patients without a complete response (5.0 vs. 9.0 mm; P <0.05). Based on the post-treatment EUS examination, the accuracy was 59% for T stage and 59&percnt for node (N) stage. The accuracy of EUS in patients treated by surgery alone was 94% for T stage and 94% for N stage, indicating a significant reduction in the accuracy of EUS in patients following chemoradiotherapy (P <0.05). The accuracy of EUS examination in patients with carcinoma of the esophagus treated by chemoradiotherapy was poor. EUS did not detect downstaging of the primary tumor, even in the presence of a complete pathologic response. EUS assessment of maximum tumor depth was a better measure of response to therapy.