Systematic review to assess the possibility of return of cerebral and cardiac activity after normothermic regional perfusion for donors after circulatory death.

BACKGROUND: Normothermic regional perfusion (NRP) is a novel technique that aids organ recovery from donors after circulatory death (DCDs). However, ethical concerns exist regarding the potential return of spontaneous cerebral and cardiac activity (ROSCCA). This study aimed to determine the likelihood of ROSCCA in NRP-DCDs of abdominal organs. METHODS: Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OOHCA) was identified as a comparator for NRP-DCDs and as a validation cohort. A systematic search identified all articles relating to NRP-DCDs and ECPR-OOHCA. Rates of ROSCCA and survival outcomes (ECPR-OOHCA only) were recorded and analysed according to the duration of no perfusion. RESULTS: In NRP-DCDs, 12 of 410 articles identified by database searching were eligible for inclusion. There were no instances of ROSCCA recorded among 493 donors. In ECPR-OOHCA, eight of 947 screened articles were eligible for inclusion (254 patients). Where the absence of perfusion exceeded 5 min in ECPR-OOHCA, there were no survivors with a favourable neurological outcome. CONCLUSION: ROSCCA is unlikely following commencement of NRP and has not occurred to date. Strict observance of the 5-min interval following asystole provides satisfactory assurance that ROSCCA will not occur following NRP.

Scan-directed mini-incision focused parathyroidectomy: how accurate is accurate enough?

INTRODUCTION Mini-incision focused parathyroidectomy (MI-FP) is advocated as an alternative to bilateral neck exploration (BNE), owing to its reduced morbidity. The site and side of the affected gland is identified preoperatively using a combination of ultrasound and sestamibi scans. However, the acceptable degree of inter-scan concordance required to prompt MI-FP without compromising accuracy is undetermined. METHODS Accuracy of preoperative imaging was determined both individually and in combination for all parathyroidectomies (2007-2014). A grading system (excellent, good, poor) was devised to describe the interscan concordance, which was validated by the operative and histological findings. RESULTS Eighty-nine patients (17 male, 68 female) underwent parathyroidectomy (MI-FP 44, BNE 45). The accuracy of scans interpreted individually was 53% for ultrasound and 60% for sestamibi, with no difference according to surgical technique (P = 0.43, P = 1, respectively). The proportion of interscan concordance was: excellent - 35%, good - 40%, poor 25%. Combined accuracy was 100% for both excellent and good grades but only 13% for those graded poor. Similar rates of normocalcaemia were observed for MI-FP and BNE, while postoperative hypocalcaemia was five times higher in those undergoing BNE. CONCLUSIONS Reduction in the inter-scan concordance from excellent to good does not compromise accuracy. MI-FP could be successfully performed in up to 75% of patients - 25% higher than recommended in national guidelines. Focused parathyroidectomy does not compromise surgical and endocrinological outcomes but boasts a far superior complication rate.

A prospective cross-sectional study of laparoscopic subtotal Lind fundoplication for gastro-oesophageal reflux disease--a durable and effective anti-reflux procedure.

INTRODUCTION: Laparoscopic partial fundoplication for gastro-oesophageal reflux disease (GORD) is reported to have fewer side effects when compared to Nissen fundoplication, but doubts remain over its long term durability in controlling reflux. The aim of this study was to assess outcome of symptoms for all patients presenting with GORD undergoing routine laparoscopic subtotal Lind fundoplication. MATERIALS & METHODS: All patients undergoing laparoscopic fundoplication between August, 1999 and November, 2007 performed by a single surgeon were included in the study. The anti-reflux procedure studied was laparoscopic Lind (300°) fundoplication with crural repair in all cases. Patients completed pre and post-operative questionnaires containing validated scoring systems for heartburn, gas bloat, dysphagia and overall patient satisfaction. RESULTS: Over the 100-month period, 320 consecutive patients underwent laparoscopic subtotal Lind fundoplication. Of these, 256 (80%) replied to the questionnaire at a mean of 31 months (range 3-96 months) following surgery. 91.4% of respondents had an improvement in heartburn symptom score with a significant reduction in score from 7.74 preoperatively to 1.25 postoperatively (p<0.001). There was also a significant reduction of mean modified Visick score for reflux control (heartburn and regurgitation) from 3.49 preoperatively to 1.48 after surgery (p<0.001). In total, 22 patients developed recurrent reflux symptoms with half of these reporting their recurrence within two years following surgery. Because of this all were tested with post-operative pH testing, yet only one had a 24-h pH time outside the normal range. Overall patient satisfaction was high with a visual analogue score of 9 and 88% of the patients claimed they would have the operation again. CONCLUSION: Laparoscopic Lind fundoplication demonstrates excellent reflux control when performed routinely for all patients presenting with GORD. This technique is both durable and efficacious in controlling reflux symptoms.

Malignant sigmoidoduodenal fistula.

INTRODUCTION: Duodenocolic fistula is a rare complication of malignant colonic disease especially when involving and originating from the sigmoid colon. We aim to discuss the unusual clinical presentation of this case as well as the investigation and management of duodenocolic fistulas. PRESENTATION OF CASE: A 91 year old lady presented as an emergency to a general surgical service at a District General Hospital with diarrhoea, vomiting and weight loss. Computed Tomography (CT) reported a large ovarian cyst elevating the sigmoid colon into immediate proximity of the duodenum. Adenocarcinoma was confirmed on histology obtained by colonoscopy. A classic apple core lesion with fistulating tract from the sigmoid colon to the duodenum was synchronously demonstrated on barium enema. DISCUSSION: Sigmoido-duodenal fistulae represent a complex manifestation of gastrointestinal pathologies. CONCLUSION: Management options must be considered in the context of patient wishes, their co-morbidities, and predicted post-operative outcome. In most cases this is likely to represent a non-operative approach, however surgical resection may benefit selected cases on occasion.

Spontaneously perforated pyometra: an unusual cause of acute abdomen and pneumoperitoneum.

Pneumoperitoneum is usually associated with gastrointestinal perforation or following surgical and endoscopic procedures. We report a rare case of spontaneously perforated pyometra presenting with generalised peritonitis and pneumoperitoneum. Perforation of the uterus is also unusual and often associated with the presence of an intrauterine device, a gravid uterus or malignancy. Our case illustrates the importance of clinical knowledge of acute and neoplastic gynaecological diseases, which are not uncommonly encountered by the general surgeon. Moreover, good appreciation of pelvic anatomy and close collaboration with gynaecology colleagues is essential as operative intervention is often required.

Invasive and surgical procedures in pre-hospital care: what is the need?

BACKGROUND: On occasion, advanced invasive procedures in pre-hospital care can be life saving. This study aimed to identify the contemporary use of these procedures on a regional doctor-led air ambulance unit, and to define the need, skill set and training requirements for a regional pre-hospital team in the UK. METHODS: Mission data were recorded prospectively and the database reviewed to identify invasive procedures over a 76-month period. These cases were reviewed with indications, mechanism of injury, presence of cardiac arrest at any time point (±return of spontaneous circulation) and procedural failure or morbidity. RESULTS: Two hundred and thirty-five procedures were performed: 16 for injuries affecting the airway, 111 for breathing and 108 for circulation. Almost a third of patients in cardiac arrest regained spontaneous circulation. Procedures performed increased fivefold from 2003 to 2009, with a marked increase in the use of thoracostomy and intra-osseous access. Procedural failure or inadequacy was high with needle cricothyroidotomy, needle chest decompression and early intra-osseous access experience. CONCLUSIONS: A steady increase in the number of procedures was observed over time. Less invasive methods of airway and breathing support were frequently inadequate, though definitive surgical airway or chest decompression was effective each time it was performed. Thoracotomy was performed infrequently. There are implications for the training of pre-hospital doctors who work in the majority of the UK.

Primary hyperparathyroidism: how many cases are being missed?

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a common condition (250 per million population per year) with significant associated morbidity and mortality. Surgery is the only curative option for PHPT; results from medical treatment remain disappointing. The aim of this study was to evaluate the referral patterns of patients with PHPT and identify the number of missed cases with a biochemical diagnosis of PHPT. MATERIALS AND METHODS: All chemistries for Worcestershire were performed and analysed at the Worcestershire Royal Hospital. Patients with chronic renal failure were identified and excluded. Routes of patient referral were identified and missed cases documented. General practitioners (GPs) were contacted by letter for all patients not referred or treated. Outcomes of diagnosis and specialist assessment were recorded. RESULTS: A total of 102 cases of PHPT were identified: 64 (62.7%) remained untreated and without a specialist referral in place, 36 (35.3%) had undergone parathyroidectomy and 2 (2.0%) were being monitored. The GP response rate was 90% (46/51). Of these, 30 (65%) were subsequently referred, 9 (20%) underwent repeat tests with a view to referral and 7 (15%) were lost to follow up. CONCLUSIONS: A significant proportion of patients with PHPT remain in the community untreated and having not seen a specialist. All patients should be referred to a specialist for assessment and consideration of surgical treatment and follow-up. Improvements in GP education and referral systems are required if patients are to benefit.