O2 No Longer the Go2: A Systematic Review and Meta-Analysis Comparing the Effects of Giving Perioperative Oxygen Therapy of 30% FiO2 to 80% FiO2 on Surgical Site Infection and Mortality.

OBJECTIVE: To determine the effects of perioperative high (80%) versus low (30%) fraction of inspired oxygen (FiO2) on surgical site infection (SSI) and mortality in adult surgical patients. BACKGROUND: The routine use of high fraction perioperative oxygen in patients is "standard of care" and recommended by the World Health Organisation; however, whether there is truly any benefit to this therapy has been challenged by some authors. Questions have also been raised about the possibility of harm from oxygen therapy. METHOD: Randomised control trials comparing high-to-low FiO2 were located by searching MEDLINE, Embase, CENTRAL and Web of Science. The primary outcomes were SSI up to 15 days and up to any time point postoperatively and mortality up to 30 days. The data were analysed using random effects meta-analysis. RESULTS: Twelve studies involving 10,212 participants were included. At 15 days postoperatively, and at the longest point of post-operative follow-up, there was no statistically significant reduction in the risk of SSI when comparing patients who received a perioperative FiO2 of 30% to those with an FiO2 of 80% (RR 1.41, 95% CI 1.00-2.01, p 0.05 and RR 1.23, 95% CI 1.00-1.51, p 0.05). There was no statistically significant difference in mortality between the 30% FiO2 and the 80% FiO2 groups (RR 1.12, 95% CI 0.56-2.22, p 0.76). CONCLUSION: This meta-analysis showed no statistically significant difference in post-operative SSI or mortality when comparing patients receiving an FiO2 of 80% to those receiving an FiO2 of 30%.

Predicting patient dissatisfaction following laparoscopic Nissen fundoplication: an analysis of symptoms.

BACKGROUND: Nissen fundoplication is a well-established treatment for gastroesophageal reflux disease (GERD) with a high success rate and a long-lasting effect. However, the literature reports that a persistent, small group of patients is not fully satisfied with the outcome. Identifying this patient group preoperatively would prevent disappointment for both patients and surgeon. This has proven difficult since dissatisfaction was related to nondisease-related factors instead of typical symptoms of GERD or the objective findings of investigations. We studied our series of patients who underwent laparoscopic Nissen fundoplication to identify predictors of patient dissatisfaction and the impact of surgery on individual symptoms. METHODS: All consecutive private patients undergoing Nissen fundoplication were asked to complete a preoperative and postoperative questionnaire concerning symptoms, medication use, and satisfaction. Demographics, investigations, complications, and reinterventions were documented. A standard laparoscopic Nissen fundoplication was performed. RESULTS: Over an 11-year period 222 patients underwent surgery for GERD. The postoperative response rate to the questionnaire was 77.5 %, with dissatisfaction reported by 12.8 % of the patients. Of these dissatisfied patients, only 13.6 % had proven disease recurrence. Both satisfied and dissatisfied patients presented with an inconsistent pattern of symptoms. None of the preoperative symptoms and investigations or the patient's age and gender was predictive of postoperative dissatisfaction. Only postoperative heartburn, regurgitation, and bloating significantly correlated with patient dissatisfaction. CONCLUSION: Nissen fundoplication has a very high satisfaction rate overall. A small percentage of patients are not fully satisfied and dissatisfaction is associated with reported persistent symptoms and side effects of surgery rather than gender or preoperative symptom pattern, severity of esophagitis, or total 24 h esophageal acid exposure.

C-reactive protein is a useful negative predictor of anastomotic leak in oesophago-gastric resection.

BACKGROUND: Post-operative C-reactive protein (CRP) has been investigated as a predictor of anastomotic leak (AL) following colorectal surgery, but its role in oesophago-gastric surgery is not yet established. METHODS: Clinical data and post-operative CRP values of patients who underwent elective oesophago-gastric resection between January 2004 and July 2014 were analysed retrospectively. Only patients with an oesophageal anastomosis were included. AL was defined as leakage of contrast material seen on imaging or a leak confirmed intraoperatively on return to theatre. RESULTS: One hundred and forty-five patients were identified. Of the 145 patients, 13 (9%) developed AL. The CRP on post-operative days (POD) 2, 3 and 6 had the greatest diagnostic accuracy, with an area under the curve of 0.82, 0.80 and 0.91 respectively. Using a cut-off value of 209 mg/L on POD 2, the sensitivity was 100%, the specificity was 61%, the positive predictive value (PPV) was 21% and the negative predictive value (NPV) was 100%. Using a cut-off value of 190 mg/L on POD 3, the sensitivity was 100%, the specificity was 59%, the PPV was 21% and the NPV was 100%. Using a cut-off value of 154 mg/L on POD 6, the sensitivity was 100%, the specificity was 78%, the PPV was 29% and the NPV was 100%. CONCLUSION: Post-operative CRP is an accurate negative predictive test for the development of AL following oesophago-gastric surgery. It may help to discriminate between patients with a high risk of leak and those in which AL is unlikely to occur.

Gall bladder polyps in sclerosing cholangitis: does the 1-cm rule apply?

INTRODUCTION: Polyps of the gall bladder (PLG) are common findings in radiological investigations of the gall bladder and most are benign although carcinoma of the gall bladder can arise in PLG. In the general population PLG less than 1 cm in diameter are thought to have a low risk of malignancy and can be cautiously observed. METHODS: All patients undergoing surgical resection for gall bladder cancer were entered into a prospective database. Four patients with primary sclerosing cholangitis (PSC) presenting with gall bladder cancer in a PLG are studied. RESULTS: Four patients (two men; median age 46.5 years, range 37-71 years) presented with PLG and known histories of PSC. All patients were shown to have PLG of size between 7 mm x 8 mm and 25 mm x 14 mm on imaging with no radiological evidence of carcinoma. Tumour markers carcinoembryonic antigen and CA19-9 were within the normal range in all patients. All patients were managed with cholecystectomy. Two patients with T1 tumours remain alive and well at 2 and 4 years post-cholecystectomy. Of the remaining two patients with T2 tumours, one underwent re-resection of the liver bed and portal lymph nodes and remains alive and well at 12 months. The remaining patient developed an abdominal wall recurrence 12 months after cholecystectomy. She has also undergone resection with postoperative radiation therapy and remains well after 12 months of clinical follow up. CONCLUSION: Gall bladder polyps, which are common and are usually benign in the general population, are often malignant in PSC. Regardless of size, any PLG in a patient with PSC should be considered for cholecystectomy.

Prevalence of hepatitis C among injecting drug users attending drug clinics.

BACKGROUND: Chronic hepatitis C (HCV) infection is an important public health issue in New Zealand, and an increasing cause of advanced liver disease. METHOD: This study examined the 2015 data on hepatitis C serology in patients on opiate substitution at four Alcohol and Drug Services, as well as rates of referral and responses to treatment for HCV. RESULTS: Among 579 patients tested, 439 (76 %) were positive for HCV antibody. For a subgroup of patients, those who reported their first use of injecting since 2010, the prevalence of HCV antibody was 48%. Among 405 patients with PCR/viral load test on file, 206 had a positive result when most recently tested. In all, 191 patients were referred for treatment, and of the 91 treated, 68 achieved viral clearance. Overall, it was found that 131 (32%) patients with a PCR/viral load test on file had cleared the HCV without treatment, as indicated by at least one negative PCR. CONCLUSIONS: HCV remains highly prevalent in injecting drug users attending these clinics, with no important reduction in infection rates from past studies. There appears to be considerable rates of spontaneous viral clearance. Nevertheless, it remains important, from individual and public health perspectives, to refer patients for treatment, which is becoming increasingly effective and safe.

Achalasia: a 13-year, single-centre experience comparing endoscopic balloon dilatation and laparoscopic Heller myotomy.

BACKGROUND: Idiopathic achalasia is a non-curable, primary motility disorder of the oesophagus. Most established long-term palliative treatment options are laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (BD). AIM: We aimed to compare the outcome of both therapies and the risk of serious complications, defined as perforation or death, in a single-centre series. METHOD: In this retrospective study, patients with BD or LHM were identified from 1997-2010. The symptom score (modified Zaninotto score) before treatment and at time of interview was evaluated via a telephone questionnaire. RESULTS: Ninety-nine patients fulfilled the inclusion criteria and treatment was provided with BD-only in 63, surgery-only in 23, BD crossover to surgery in 12, and surgery crossover to BD in one patient. Mean age was 62 years in the BD-only, and 39 years in the surgery-only group. One hundred and fifteen BD were performed on 76 patients with multiple dilatations required in 46 patients (38%). Sixty-four percent of all patients alive (n=81) were interviewed. Satisfactory outcomes were achieved in 79% in the BD group and in 88% in the surgery group, with a mean follow-up of 81 and 69 months, respectively. There was a single perforation in the BD group (0.9%) and no deaths occurred. CONCLUSION: LHM and on-demand BD were safe and within the limitations of our study design both methods appeared similarly effective treatments for achalasia, resulting in a satisfactory outcome in 88% and 79% of patients with a mean follow-up of 69 and 81 months. Serious complications occurred in less than 1% of procedures and there were no deaths.

Management of primary group A streptococcal peritonitis: a systematic review.

BACKGROUND: Over the past 20 years, there has been a global increase in the incidence and severity of group A streptococcal diseases. Primary group A streptococcal peritonitis is a life-threatening disease that may present in previously healthy individuals and progress to shock and severe organ dysfunction within a few hours. Our goal was to develop recommendations regarding the care of this group of patients. METHODS: A systematic review of all adult cases of primary group A streptococcal peritonitis described in the English-language literature between January 1990 and December 2011. RESULTS: Thirty-two patients with a median age at diagnosis of 38 years and a male:female ratio of 1:4 are described. Exploratory laparotomy was performed in 25 patients, 17 of whom had undergone abdominal computed tomography (CT). Laparoscopic peritoneal lavage was performed in five patients, and, in two patients, no operative interventions were undertaken. CONCLUSION: The worrisome increase in invasive group A streptococcal disease means that presentations of primary group A streptococcal peritonitis are likely to become more common. The challenge for the treating surgeon is to consider the possibility of this diagnosis. In the current era of multi-detector CT technology, secondary peritonitis from an intra-abdominal source may be excluded reliably using abdominal CT. Exploratory laparotomy is not mandated, and paracentesis is sufficient to confirm the diagnosis and avoid operative morbidity in patients with localized intra-peritoneal fluid collections. Laparoscopic peritoneal lavage should be reserved for patients with widespread intra-peritoneal free fluid or whose condition deteriorates despite antibiotic therapy.

Primary oesophageal malignant melanoma.

INTRODUCTION: Primary oesophageal malignant melanoma is an extremely rare disease. While this aggressive tumour is generally considered to have a dismal prognosis, long-term survival can be achieved by radical resection in selected cases. CONCLUSIONS: We report two cases of primary oesophageal malignant melanoma treated with Ivor-Lewis oesophagogastrectomy and review the literature.