A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION: Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC. METHODS: A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed. RESULTS: Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy. CONCLUSIONS: LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

AMR Sign - An Arthroscopic S-shaped Fold Signifying Adequate Medial Meniscus Repair.

Introduction: The preferred management of medial meniscus tears has notably moved from meniscectomies towards repair. With a higher volume of meniscal repairs being done all across the world with every passing day, the lack of an objective and definitive sign suggesting the adequacy of its repair is daunting. The purpose of our study was to introduce a unique and novel arthroscopic sign formed after adequate repair of the medial meniscus, the AMR (Adequacy of Medial meniscus Repair) sign. We hypothesised that it is not only the objective end point for repair, but can also form the indicator for excellent clinical, functional, and radiological outcome even in the long term. Materials and methods: This was a multicentric, prospective study initiated by the corresponding author, and the findings validated subsequently by the other authors. Overall, it included 804 patients of isolated medial meniscus tear operated with arthroscopic all-inside technique between January 2014 and December 2017. Patients were segregated into three groups based on whether an S-shaped curve in the free, inner edge of the medial meniscus sign was formed post-repair, lost after further tightening, or not formed upon subjective completion of repair. All the patients were followed-up and evaluated based of medial joint line tenderness, McMurray's test for medial meniscus, IKDC score, WOMET score, and radiologically using an MRI at the terminal follow-up. Results: The mean terminal follow-up was 42.34±4.54 months. There was significant (p<0.01) improvement in all patients at the terminal follow-up post-surgery, irrespective of the group. The group in which AMR sign was formed and maintained showed a significantly better functional outcome on terminal follow-up as well as lower failure rates compared to the other two groups. Conclusion: AMR sign is an S-shaped fold at the inner, free edge of medial meniscus, formed after an adequate repair of isolated medial meniscus tear, as viewed on arthroscopy. It is an objective sign denoting regained integrity of the collagen architecture of the medial meniscus following repair. It is also a reliable indicator of excellent long term functional, clinical, and radiological outcome and also lower failure rates in patients after arthroscopic medial meniscus repair.

National Joint Registry recorded untoward intraoperative events during primary total hip arthroplasty: an investigation into the data accuracy, causal mechanisms and attributability.

INTRODUCTION: Untoward intraoperative events occurring during total hip arthroplasty are recorded by the National Joint Registry through Minimum Data Set (MDS) forms. This data may be used to assess the safety of implants. The aim of this study is to evaluate the accuracy of the untoward intraoperative events, assess the mechanism and ascertain whether these events were attributable to the implants inserted. METHODS: A retrospective analysis was undertaken of primary total hip arthroplasties performed between 2005 and 2018 in which an untoward intraoperative event was recorded. RESULTS: Of 12,802 primary hip replacements, 64 patients (0.5%) had untoward intraoperative events recorded on the MDS form. In 43 of 64 cases, the intraoperative untoward event recorded on the MDS form matched the operation notes. Among these 43 cases, in 30 (69%) patients the intraoperative event could be attributed to the implant recorded. In the remaining 13 (31%) cases, the events recorded could not be attributed to the implant. In six cases, the untoward events were attributed to implants used to manage the events rather than the implants which caused them. In seven cases, the untoward events were related to surgical technique rather than to the implant or instrumentation. CONCLUSIONS: Our analysis highlights that all untoward intraoperative events recorded on the NJR form are not implant related or attributable to the implant inserted. Provision should be made on the MDS form to clarify whether a particular untoward intraoperative event was related to the implant inserted.

A real-time electronic symptom monitoring system for patients after discharge following surgery: a pilot study in cancer-related surgery.

BACKGROUND: Advances in peri-operative care of surgical oncology patients result in shorter hospital stays. Earlier discharge may bring benefits, but complications can occur while patients are recovering at home. Electronic patient-reported outcome (ePRO) systems may enhance remote, real-time symptom monitoring and detection of complications after hospital discharge, thereby improving patient safety and outcomes. Evidence of the effectiveness of ePRO systems in surgical oncology is lacking. This pilot study evaluated the feasibility of a real-time electronic symptom monitoring system for patients after discharge following cancer-related upper gastrointestinal surgery. METHODS: A pilot study in two UK hospitals included patients who had undergone cancer-related upper gastrointestinal surgery. Participants completed the ePRO symptom-report at discharge, twice in the first week and weekly post-discharge. Symptom-report completeness, system actions, barriers to using the ePRO system and technical performance were examined. The ePRO surgery system is an online symptom-report that allows clinicians to view patient symptom-reports within hospital electronic health records and was developed as part of the eRAPID project. Clinically derived algorithms provide patients with tailored self-management advice, prompts to contact a clinician or automated clinician alerts depending on symptom severity. Interviews with participants and clinicians determined the acceptability of the ePRO system to support patients and their clinical management during recovery. RESULTS: Ninety-one patients were approached, of which 40 consented to participate (27 male, mean age 64 years). Symptom-report response rates were high (range 63-100%). Of 197 ePRO completions analysed, 76 (39%) triggered self-management advice, 72 (36%) trigged advice to contact a clinician, 9 (5%) triggered a clinician alert and 40 (20%) did not require advice. Participants found the ePRO system reassuring, providing timely information and advice relevant to supporting their recovery. Clinicians regarded the system as a useful adjunct to usual care, by signposting patients to seek appropriate help and enhancing their understanding of patients' experiences during recovery. CONCLUSION: Use of the ePRO system for the real-time, remote monitoring of symptoms in patients recovering from cancer-related upper gastrointestinal surgery is feasible and acceptable. A definitive randomised controlled trial is needed to evaluate the impact of the system on patients' wellbeing after hospital discharge.

Impact of bariatric surgery on cardiovascular outcomes and mortality: a population-based cohort study.

BACKGROUND: Cohort studies have shown that bariatric surgery may reduce the incidence of and mortality from cardiovascular disease (CVD), but studies using real-world data are limited. This study examined the impact of bariatric surgery on incident CVD, hypertension and atrial fibrillation, and all-cause mortality. METHODS: A retrospective, matched, controlled cohort study of The Health Improvement Network primary care database (from 1 January 1990 to 31 January 2018) was performed (approximately 6 per cent of the UK population). Adults with a BMI of 30 kg/m2 or above who did not have gastric cancer were included as the exposed group. Each exposed patient, who had undergone bariatric surgery, was matched for age, sex, BMI and presence of type 2 diabetes mellitus (T2DM) with two controls who had not had bariatric surgery. RESULTS: A total of 5170 exposed and 9995 control participants were included; their mean(s.d.) age was 45·3(10·5) years and 21·5 per cent (3265 of 15 165 participants) had T2DM. Median follow-up was 3·9 (i.q.r. 1·8- 6·4) years. Mean(s.d.) percentage weight loss was 20·0(13·2) and 0·8(9·5) per cent in exposed and control groups respectively. Overall, bariatric surgery was not associated with a significantly lower CVD risk (adjusted hazard ratio (HR) 0·80; 95 per cent c.i. 0·62 to 1·02; P = 0·074). Only in the gastric bypass group was a significant impact on CVD observed (HR 0·53, 0·34 to 0·81; P = 0·003). Bariatric surgery was associated with significant reduction in all-cause mortality (adjusted HR 0·70, 0·55 to 0·89; P = 0·004), hypertension (adjusted HR 0·41, 0·34 to 0·50; P < 0·001) and heart failure (adjusted HR 0·57, 0·34 to 0·96; P = 0·033). Outcomes were similar in patients with and those without T2DM (exposed versus controls), except for incident atrial fibrillation, which was reduced in the T2DM group. CONCLUSION: Bariatric surgery is associated with a reduced risk of hypertension, heart failure and mortality, compared with routine care. Gastric bypass was associated with reduced risk of CVD compared to routine care.

ANTECEDENTES: Estudios de cohortes han mostrado que la cirugía bariátrica puede reducir la incidencia de enfermedad cardiovascular (cardiovascular disease, CVD) y la mortalidad, pero los estudios basados en datos del mundo real son limitados. Este estudio examinaba el impacto de la cirugía bariátrica (bariatric surgery, BS) en la incidencia de CVD, hipertensión, fibrilación auricular (FA) y mortalidad por cualquier causa. MÉTODOS: Se realizó un estudio retrospectivo de cohortes, controlado por emparejamiento, a partir de la base de datos de atención primaria del The Health Improvement Network (THIN) (1/1/1990 y 31/1/2018) (aproximadamente el 6% de la población del Reino Unido UK). En el grupo de exposición, se incluyeron adultos con un índice de masa corporal (IMC) ≥ 30 kg/m2 que no tenían cáncer gástrico. Cada paciente expuesto (había sido operado de BS) fue emparejado por edad, sexo, IMC y presencia de diabetes tipo 2 (T2D) con 2 controles (sin BS). RESULTADOS: Se incluyeron un total de 5.170 sujetos expuestos y 9.995 participantes controles. La edad media (DE) fue 45,3 (10,5) años, 21,5% (n = 3.265) tenían T2D. La mediana de seguimiento era de 3,9 años (rango intercuartílico 1,8- 6,4). La media ± desviación estándar del % de pérdida de peso fue del 20,0 ± 13,2% en el grupo BS versus 0,8 ± 9,5% en los grupos control. Globalmente, la BS no se asoció con una CVD significativamente más baja (cociente de riesgos instantáneos ajustados, adjusted hazard ratio, HR 0,80; i.c. del 0,62- 1,02, P = 0,074). Solo en el grupo del bypass gástrico se observó un impacto significativo en CVD (0,53, 0,34- 0,81, P = 0,003). BS se asoció con una reducción significativa en la mortalidad de cualquier causa (0,70; i.c. Del 95% 0,55- 0,89, P = 0,004), hipertensión (0,41; 0,34- 0,50, P < 0,001), e insuficiencia cardiaca (0,57, 0,34- 0,96; P = 0.033). Los resultados fueron similares en aquellos pacientes con y sin T2D (expuesto versus control) excepto en la FA incidental que se redujo en el grupo T2D. CONCLUSIONES: La práctica de BS se asoció con una reducción del riesgo de insuficiencia cardiaca y mortalidad.

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group.

BACKGROUND: Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions. METHODS: From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years. RESULTS: Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%. CONCLUSION: Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Effect of cobalt-60 gamma radiation on total hemocyte content and biochemical parameters in Macrobrachium rosenbergii (De Man, 1879).

Purpose: The effect of low level cobalt-60 (60Co) gamma radiation on the freshwater prawn Macrobrachium rosenbergii was evaluated by observing their hemocyte counts and biochemical parameters. Materials and methods: Prawns were exposed to 3, 30, 300 and 3000 milligray (mGy) dose levels and their tissues of gills, hepatopancreas and muscle were analyzed. Results: The results showed that the number of hemocytes in the hemolymph and concentrations of protein and carbohydrate were significantly reduced in irradiated groups than compared to the control prawn. Increased aspartate transaminase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), Acetyl choline esterase (AChE) in the irradiated groups reflects tissue damage. Conclusions: Hence, this study concludes that even low level of ionizing radiation (60Co gamma) can cause acute damages in gills, hepatopancreas and muscles in irradiated groups. Highlights 60Co exposures effect the THC and biochemical of prawn M. rosenbergii. Different dose levels such as 3, 30, 300 and 3000 mGy. Biochemical parameters serve as reliable indicators of physical status of organism. Self-regulating mechanisms might be the reason for preventing from the lethality. Suggested that nuclear industries should manage below 3 mGy.

Influence of different pasteurization techniques on antidiabetic, antioxidant and sensory quality of debittered bitter gourd juice during storage.

Debittered bitter gourd juice was subjected to gamma irradiation doses of 0, 0.25, 0.5, 0.75, 1, 1.5 and 2.5 kGy and thermal pasteurization at temperatures of 65, 75, 85 and 95 °C. Shigella boydii was the most heat resistant pathogen tested (D10 of 42.8 s at 65 °C) while Bacillus cereus was the most resistant pathogen to irradiation with a D10 of 0.46 kGy. No significant (p < 0.05) effect of thermal pasteurization was observed on antidiabetic (α-amylase and α-glucosidase inhibition) activity, however, a 10% increase in α-glucosidase inhibition was observed in irradiated (2.5 kGy) samples. A significant (p < 0.05) but marginal reduction (up to 10%) was observed in antidiabetic activity during storage for a period of 90 days. Thermal pasteurization at 65 °C demonstrated significantly (p < 0.05) higher sensory quality as compared to irradiated (2.5 kGy) samples. This is first report on effect of pasteurization on antidiabetic activity of bitter gourd juice.

Changes in glycaemic control, blood pressure and lipids 5 years following laparoscopic adjustable gastric banding combined with medical care in patients with type 2 diabetes: a longitudinal analysis.

The long-term outcomes of weight loss maintenance induced by laparoscopic adjustable gastric band (LAGB) followed by multidisciplinary medical care in patients with type 2 diabetes mellitus (T2DM) (beyond 3 years) are scarcely reported. Study aims were to determine the longer term metabolic outcomes following LAGB combined with medical care in patients with T2DM. This is a longitudinal analysis of 200 adults with T2DM who had LAGB between 2003 and 2008 and were followed up till 2013 at a single bariatric unit in a tertiary UK centre. A total of 200 patients (age 47 ± 9.7 years; body mass index [BMI] 52.8 ± 9.2 kg m-2 ; glycosylated haemoglobin (HbA1c) 7.9 ± 1.9% [62.8 mmol mol-1 ]; women, n = 123 [61.5%]; insulin treatment, n = 71 [35.5%]) were included. The mean follow-up was 62.0 ± 13.0 months (range 18-84 months). There were significant reductions in body weight (-24.4 ± 12.3% [38 ± 22.7 kg]), HbA1c (-1.4 ± 2.0%), systolic blood pressure [BP] (-11.7 ± 23.5 mmHg), total cholesterol and triglyceride levels. The proportion of patients requiring insulin reduced from 36.2% to 12.3%. The overall band complication rate was 21% (21 patients). LAGB when combined with multidisciplinary medical care significantly improved metabolic outcomes in patients with T2DM independent of diabetes duration, and baseline BMI over 5 years. Diabetes duration and baseline BMI did not predict changes in glycaemic control, BP or lipids following LAGB.

The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study.

INTRODUCTION: Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks. METHODS: A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded. RESULTS: 924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1). CONCLUSION: Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.

Histological alterations in the hepatic tissues of Al2O3 nanoparticles exposed freshwater fish Oreochromis mossambicus.

Adverse effects of nanoparticles on aquatic environment and organisms have drawn much special attention to many researches. Aluminium oxide nanoparticles (Al2O3-NPs) have potential uses in varied fields and are seen entering into the ecosystem. Their potential toxicity to the freshwater fish is not much studied. Hence this study was framed to investigate the effect Al2O3 NPs on freshwater fish Oreochromis mossambicus in terms of sub lethal toxicity, histological changes and hepato somatic index (HSI) under laboratory conditions. Fishes were exposed to varying concentrations of Al2O3 NPs for 96hr. LC50 value was found to be in between 235 and 245ppm. The findings of the present work showed that the NPs were accumulated in the fish liver and caused major histological anomalies such as structural alterations in the portal vein, necrotic hepatocytes, vacuolation, aggregation of blood cells and melanomacrophages. Significant histological alterations were observed in the highest concentration. Our results evidenced that the Al2O3 NPs in the aquatic environment affects the health condition of the fishes.

Vertical distribution, composition profiles, sources and toxicity assessment of PAH residues in the reclaimed mudflat sediments from the adjacent Thane Creek of Mumbai.

A study on vertical distribution of magnetic susceptibility, carcinogenic and endocrine disrupting PAHs was performed in the reclaimed mudflat sediments adjacent to the Thane Creek of Mumbai. The 5-rings PAHs and ΣC-PAHs were more dominant at 120cm depth contributing 52.23% and 60.19% respectively to ∑PAHs. The average ratio values of LMW/HMW PAHs (0.58); Fla/(Fla+Pyr) (0.50); Ant/(Ant+Phe) (0.50); BaA/(Chry+BaA) (0.48); BaP/BghiP (2.06), Phe/Ant (1.03) and BaA/Chr (0.93) indicate that the PAH contamination might have raised due to inefficient combustion and pyrogenic emissions during the open burning of solid waste in the vicinity. This was further supported by the anthropogenic ferri(o)magnetic loading over the last 100years influencing the Creek sediments. The PAHs toxicity estimation was performed by calculating the toxic equivalent quantity (TEQ) value of 8.62ng TEQ/g which was below the safe level (600ng TEQ/g) suggested by the Canadian risk-based soil criterion for protection of human health.

Mortality related to primary bariatric surgery in England.

BACKGROUND: Bariatric surgery is an accepted treatment option for severe obesity. Previous analysis of the independently collected Hospital Episode Statistics (HES) data for outcomes after bariatric surgery demonstrated a 30-day postoperative mortality rate of 0·3 per cent in the English National Health Service (NHS). However, there have been no published mortality data for bariatric procedures performed since 2008. This study aimed to assess mortality related to bariatric surgery in England from 2009. METHODS: HES data were used to identify all patients who had primary bariatric surgery from 2009 to 2016. Clinical codes were used selectively to identify all primary bariatric procedures but exclude revision or conversion procedures and operations for malignant or other benign disease. The primary outcome measures were HES in-hospital and Office for National Statistics (ONS) 30-day mortality after discharge. RESULTS: A total of 41 241 primary bariatric procedures were carried out in the NHS between 2009 and 2016, with 29 in-hospital deaths (0·07 per cent). The 30-day mortality rate after discharge was 0·08 per cent (32 of 41 241). Both the in-hospital and 30-day mortality rates after discharge demonstrated a downward trend over the study period. CONCLUSION: Overall in-hospital and 30-day mortality rates remain very low after primary bariatric surgery. An increased uptake of bariatric surgery within the English NHS has been safe.

A decade of day-case endoscopically guided stent placement in malignant oesophagogastric strictures.

BACKGROUND: Self-expanding metal stents (SEMSs) are the palliative treatment of choice for rapid symptomatic relief in patients with malignant dysphagia. Increasingly endoscopically guided insertion is performed as a day case and without the need for fluoroscopic guidance. This consecutive case series reports 11-year experience of endoscopically guided SEMS insertion in a large UK specialist oesophagogastric unit. METHODS: Patients undergoing stent insertion for malignant dysphagia between 2003 and 2014 were identified from a prospectively maintained database. Data on patient demographics, tumour characteristics, indications, technique of insertion, complications, and need for re-intervention were abstracted and then corroborated by retrospective review of electronic case records. RESULTS: A total of 362 patients with a median age of 76 years underwent primary SEMS insertion under endoscopic guidance. Repeat endoscopic intervention was required in 26 patients within 30 days and 59 patients within 90 days of primary insertion, giving Kaplan-Meier estimated re-intervention rates of 7.7 % and 20.3 %, respectively. Higher tumours were associated with need for repeat intervention (p = 0.014). The most frequent repeat intervention was insertion of a new stent, most commonly for stent migration or tumour overgrowth. Out of 252, 222 (88.1 %) patients referred through a rapid access pathway were stented as day cases, and the 30-day readmission rate in this cohort did not differ significantly from patients stented as inpatients (p = 0.774). Three (0.8 %) patients suffered a perforation, and there was a single procedure-related death. CONCLUSIONS: This large consecutive case series demonstrates that endoscopically guided SEMS insertion in malignant dysphagia can be performed efficiently as a day case with low complication, readmission, and re-intervention rates.

An "all 5 mm ports" technique for laparoscopic day-case anti-reflux surgery: A consecutive case series of 205 patients.

INTRODUCTION: Laparoscopic anti-reflux surgery is conventionally performed using two 10/12 mm ports. While laparoscopic procedures reduce post-operative pain, the use of larger ports invariably increases discomfort and affects cosmesis. We describe a new all 5 mm ports technique for laparoscopic anti-reflux surgery and present a review of our initial experience with this approach. METHODS: All patients undergoing laparoscopic fundoplication over a 35 month period from February 2013 under the care of a single surgeon were included. A Lind laparoscopic fundoplication was performed using an all 5 mm port technique. Data was recorded prospectively on patient demographics, operating surgeon, surgical time, date of discharge, readmissions, complications, need for re-intervention, and reasons for admission. RESULTS: Two hundred and five consecutive patients underwent laparoscopic fundoplication over the study period. The all 5 mm port technique was used in all cases, with conversion to a 12 mm port only once (0.49%). Median operating time was 52 min 185 (90.2%) patients were discharged as day cases. Increasing ASA grade and the presence of a hiatus hernia were associated with the need for overnight stay with admission required in 33% of patients with ASA 3, compared to 4% with ASA 1 (p = 0.001), and 29% of those with a hiatus hernia vs. 5% without (p < 0.001). No port-related complications occurred, and no patients developed recurrence of reflux symptoms. A single patient required mesh repair of a large hiatus hernia. CONCLUSION: The all 5 mm ports approach to laparoscopic anti-reflux surgery is a safe, efficient, and cost-effective technique which facilitates same day discharge and minimises port related complications. National commissioning guidelines in the UK should target quality improvements in anti-reflux surgery based around day-case management. This would improve the service for these patients and culminate in cost savings for the NHS.

Day surgery for achalasia cardia: Time for consensus?

INTRODUCTION: Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS: We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS: Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS: LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.

Reducing same day cancellations due to patient related factors in elective orthopaedic surgery: experience of a centre in the UK.

Cancellations on the day of surgery represent a major wastage of resources and can impose significant distress on patients. Minimising same day cancellations can improve cost effectiveness of operating theatre running. The aim of the study was to determine the impact of administering a questionnaire, by phone to elective orthopaedic patients, the week prior to surgery. This questionnaire was aimed at identifying factors that could lead to same day cancellation for patient related reasons. The questionnaire was administered to elective orthopaedic patients over a nine month period. The rate of same day cancellations due to patient related reasons in this cohort (Phase 2) was compared with a previous cohort assessed over a five month period when the questionnaire was not in place (Phase 1). Administering the questionnaire reduced the same day cancellations due to patient reasons from 11 out of 110 (10%) to 2 out of 118 (1.60%) (p = 0.01). Theatre wastage in terms of national tariff lost due to cancellations was reduced from 25,881 sterling pounds to 1,650 sterling pounds (p<0.001). The study concludes that administering a questionnaire aimed at addressing patient related reasons can significantly reduce same day cancellations.

Management of temporomandibular joint ankylosis type III: lateral arthroplasty as a treatment of choice.

Many surgical techniques for the management of temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this study was to report our experience using a lateral arthroplasty technique in the management of type III ankylosis. The records of 15 patients treated for TMJ ankylosis at our institution between 2007 and 2011 were reviewed. Pre- and postoperative information collected included age, gender, aetiology, ankylosis type/classification, existing facial asymmetry, maximum pre- and postoperative mouth opening, complications, and recurrence of ankylosis. The mean maximum inter-incisal opening in the preoperative period was 12.9 mm and in the postoperative period was 36.2mm. No major complication was observed in any patient. No recurrence was noted in any patient. Our working hypothesis was that for patients with ankylosis type III, the medially displaced condyle and disc can fulfil their role in mandibular function and growth after extirpation of the ankylozed mass. Although they are located in an awkward medial position, they should function exactly as they would after a properly treated, displaced condylar fracture.