Transgastric drainage of the perforated esophagus: our experiences over 10 years.

We first described the technique of transgastric drainage of esophageal injuries in 2008. The method establishes vacuum drainage of the lumen of the esophagus, while maintaining patency, effectively exteriorizing the perforation to allow healing. We summarize this technique and present our experiences from the largest published series of patients. Our unit has treated selected esophageal injuries with transgastric drainage for 10 years. Indications include perforations not amenable to primary repair and treatment failure following prior surgical intervention. A 36 French silastic chest drain is pulled through the abdominal and stomach wall and introduced into the esophagus so that it crosses the perforation. Gastropexy is performed. Mediastinal decontamination and drainage are performed as needed. Continuous suction of -10 cm water is applied. Leak resolution is assessed with weekly water-soluble swallows. For this retrospective observational study, we analyzed data for patients with esophageal perforation, between 2012 and 2022. Inpatient mortality and time to leak resolution were set as primary and secondary outcomes. Esophageal perforations were treated with transgastric drain in 35 patients, of whom 68% (n = 24) were men. Median age was 67 (26-84). Spontaneous perforations accounted for 60% (n = 21), 31% (n = 11) were iatrogenic and 6% (n = 2) were ischemic. Inpatient and 30-day mortality was 14% (n = 5). Among successful treatments, the median length to resolution of leak on imaging was 34.5 days (6-80). Transgastric drainage can successfully treat esophageal perforations, where primary repair is not feasible. The mortality rate of 14% and reduced morbidity compares favorably with other traditional methods of management for esophageal perforation.

Systematic review of quality of life after esophagectomy and total gastrectomy in patients with gastro-esophageal junction cancer.

The optimal management of cancer of the gastro-esophageal junction (GEJ) is an area of contention. GEJ tumors are typically resected via total gastrectomy or esophagectomy. Despite many studies aiming to determine the superiority of either procedure based on surgical or oncological outcomes, the evidence is equivocal. Data focusing specifically on quality of life (QoL), however, is limited. This systematic review was performed to determine if there is any difference in patient's QoL after total gastrectomy or esophagectomy. A systematic search of PubMed, Medline and Cochrane libraries was conducted for literature published between 1986 and 2023. Studies that used the internationally validated questionnaires EORTC QLQ-C30 and EORTC-QLQ-OG25, to compare QoL after esophagectomy to gastrectomy for the management of GEJ cancer were included. Five studies involving 575 patients undergoing either esophagectomy (n = 365) or total gastrectomy (n = 210) for GEJ tumors were included. QoL was predominantly assessed at 6, 12 and 24 months postoperatively. Although individual studies demonstrated significant differences in certain domains, these differences were not consistently demonstrated in more than one study. There is no evidence to suggest any significant differences in QoL after total gastrectomy compared to esophagectomy for management of gastro-esophageal junction cancer.

Oesophagectomy or Total Gastrectomy for the Management of Siewert II Gastroesophageal Junction Cancer: a Systematic Review and Meta-analysis.

BACKGROUND: There is no consensus on the ideal surgical management of patients with Siewert type II gastroesophageal junctional (GEJ) cancers. Due to its anatomical location, total gastrectomy and oesophagectomy are widely used methods of resection. The aim of this study was to determine the optimal surgical treatment of these patients. METHOD: A systematic search of PubMed, Medline and Cochrane libraries was conducted for literature published between 2000 and 2022. Studies directly comparing oesophagectomy to gastrectomy for Siewert type II tumours were included. Outcome measures included rates of anastomotic leak, 30-day mortality, R0 resection and 5-year survival. Statistical analysis was performed using Review Manager 5.4. RESULTS: Eleven studies involving 18,585 patients undergoing either oesophagectomy (n = 8618) or total gastrectomy (n = 9967) for Siewert type II GEJ cancer were included. There were no significant differences between the rates of anastomotic leak (OR 0.91, CI 0.59-1.40, p = 0.66) and R0 resection (OR 1.51, CI 0.93-2.42, p = 0.09). Patients undergoing total gastrectomy had a lower 30-day mortality (OR 0.66, CI 0.45-0.95, p = 0.03) and a greater 5-year overall survival (OR 1.49, CI 1.34-1.67, p < 0.001) compared to patients undergoing oesophagectomy. These differences were not statistically significant after excluding two large studies, which accounted for the majority of the total population in the analysis. CONCLUSION: These results suggest that total gastrectomy results in lower 30-day mortality and improved overall survival in patients with Siewert type II GEJ cancer. However, interpretation of these results may be biased by the effect of two large studies.

Systematic review and meta-analysis of the influence of prophylactic pyloric balloon dilatation in the prevention of early delayed gastric emptying after oesophagectomy.

BACKGROUND: Early delayed gastric emptying (DGE) occurs in up to 50% of patients following oesophagectomy, which can contribute to increased anastomotic leak and respiratory infection rates. Although the treatment of DGE in the form of pyloric balloon dilatation (PBD) post-operatively is well established, there is no consensus on the optimal approach in the prevention of DGE. The aim of this review was to determine the efficacy of prophylactic PBD in the prevention of DGE following oesophagectomy. METHOD: PubMed, MEDLINE and the Cochrane Library (January 1990 to April 2021) were searched for studies reporting the outcomes of prophylactic PBD in patients who underwent oesophagectomy. The primary outcome measure was the rate of DGE. Secondary outcome measures include anastomotic leak rate and length of hospital stay. RESULTS: Three studies with a total of 203 patients [mean age 63 (26-82) years, 162 males (79.8%)] were analyzed. PBD with a 20-mm balloon was performed in 165 patients (46 patients had PBD and botox therapy) compared with 38 patients who had either no intervention or botox alone (14 patients). The pooled rates of early DGE [16.27%, 95% CI (12.29-20.24) vs. 39.02% (38.87-39.17) (P < 0.001)] and anastomotic leak [8.55%, 95% CI (8.51-8.59) vs. 12.23% (12.16-12.31), P < 0.001] were significantly lower in the PBD group. CONCLUSION: Prophylactic PBD with a 20-mm balloon significantly reduced the rates of early delayed gastric emptying and anastomotic leak following oesophagectomy.

Nutritional deficiency post esophageal and gastric cancer surgery: A quality improvement study.

BACKGROUND: Esophagectomy or gastrectomy for malignant tumors can have a profound effect on nutritional status of patients undergoing the procedure. Hence, postoperative nutritional status is an important prognostic factor to consider in ensuring optimal recovery. In this study, we looked at assessing the prevalence of micronutrient deficiencies post esophagectomy or gastrectomies and the efficiency of Allied Health Professionals (AHP) led clinics in identifying and appropriately managing the deficiencies. METHOD: Between February 2017 and February 2018, all patients who attended the AHP clinic, had micronutrient screening, which includes ferritin, folate, vitamin B12 and vitamin D. Patients were screened for exocrine pancreatic insufficiency (EPI) through series of questions related to symptoms of EPI including steatorrhea, flatulence and urgency to defecate. All patients included in the study were started on A-Z multivitamin tablets from their first visit. Patients reporting symptoms indicative of EPI were started on Creon. Patients found deficient in any micronutrients were invited for a follow-up measurement of the respective deficiency. RESULTS: A total of 63 patients were included in the study period with a median follow-up of 18 months (range: 2-60 months) post esophagectomy and/or subtotal/total gastrectomy for malignant tumors. Proportion of patients with deficiency in ferritin, folate, vitamin B12 and vitamin D were 42.86%, 9.52%, 6.35% and 36.67% respectively. The proportion of patients identified with symptoms indicative of EPI was 31.75%. At re-test follow-up, 66.67% patient noticed settlement of symptoms of EPI. Ferritin, Folate, Vitamin B12 and D levels significantly improved post initial AHP follow-up (significance level p < 0.05). CONCLUSION: This study highlights that nutritional deficiencies post esophagectomy and/or subtotal/total gastrectomy for malignant tumors are prevalent. AHP run follow-up clinics in our unit helps identify these deficiencies and manage them accordingly. This study shows statistically significant improvement in deficiencies thereby making AHP led follow-up clinics to be cost effective and improve patient outcome.

Landline Natives: Telephone Practices since the 1950s as Innovation.

The telephone has played a key role in shaping modern life. While most scholars focus on the early use of landline telephones, this article follows the subsequent social history of landline telephones in the late twentieth century as an equally significant phase of innovation, when telephone practices changed radically as a result of transformations in national and household infrastructures. In this article, we identify a new generation of "landline natives" emerging around 1968; for them, the telephone was a natural form of communication and part of their home environments. Our case study of how telephone use became taken for granted serves as a prehistory for scholars studying cellphone and smartphone practices as well as media scholars seeking to understand audience participation in television and radio.

Independent restoration of femoral and acetabular height reduces limb length discrepancy and improves reported outcome following total hip arthroplasty.

BACKGROUND: Restoration of native hip biomechanics is viewed as a key intra-operative goal in total hip arthroplasty (THA). The transverse acetabular ligament (TAL) can aid in the restoration of acetabular height and offset, and a calliper can be utilised to restore femoral height and offset. This study aimed to determine how these techniques affected the incidence of patient perception of limb length discrepancy (LLD), and if restoration of native biomechanics correlated with improved patient outcomes. METHODS: 123 patients were questioned regarding perception of LLD at 6 weeks and 1 year following THA. Oxford hip score (OHS) and pain scores were recorded. Radiographs were analysed by a blinded clinician who measured three variables; Global hip height (surrogate for limb length), global offset and the combination of both. These measurements were then compared to the unaffected contralateral hip. Data were analysed based on hips that were restored to within ≤±10 mm of native values, and those >±10 mm. Spearman's rank test was used to assess correlation with outcome. RESULTS: 8 (6.5%) patients perceived a LLD at 6 weeks, reducing to 3 (2.4%) at 1 year-lower than generally reported. Those patients not restored within ±10 mm of native global height had increased pain at 1 year (r = 0.558, p = 0.047). Those not restored within ±10 mm native global offset had a poorer OHS at 1 year (r = -0.586, p = 0.035) and those patients with combined height and offset discrepancy >±10 mm had both a worse OHS (r = -0.581, p = 0.037) and increased pain (r = 0.783, p = 0.002). CONCLUSION: Patient perception of LLD is complex and relates poorly to radiographic measurement, however, patients not restored to within 10 mm of native hip height and offset have demonstrated poorer outcomes.

Prospective cohort study of neoadjuvant therapy toxicity in the treatment of oesophageal adenocarcinoma.

BACKGROUND: Early studies investigating the benefits of neoadjuvant therapy in oesophageal cancer showed conflicting results, taking many years before a survival advantage was demonstrated in randomised trials. Gains are modest, limited by progressive disease and toxicity. This study aimed to investigate the relationship between neoadjuvant therapy-associated toxicity and clinical outcomes including survival in patients with potentially curable oesophageal adenocarcinoma. MATERIALS AND METHODS: A cohort of 286 patients undergoing neoadjuvant therapy followed by surgical resection at a single institution was identified from a prospective database. Adverse events from neoadjuvant therapy were recorded and graded. Patients were divided into two groups according to whether they suffered toxicity or not. Clinical outcomes including whether patients completed the neoadjuvant course, whether they proceeded to resection and overall survival, were compared between the groups. RESULTS: Neoadjuvant therapy-related toxicity was identified in 67/286 patients. 46 patients suffered severe, life-threatening or fatal adverse events. In patients with toxicity, 47% did not complete the chemotherapy course compared to 17% without toxicity, RR 2.7 (95%CI 1.7-4.4), (P < 0.001). In patients suffering toxicity, 17.9% failed to proceed to resection compared with 7.8% in those without toxicity, RR 2.3 (95%CI 1.2-4.6) P = 0.02. Median overall survival was shorter in patients suffering toxicity (20.7 months) compared to those without toxicity (37.8 months), P = 0.008. When patients failing to proceed to resection were excluded, median overall survival was shorter in patients suffering toxicity (26.2 months) compared with those without toxicity (47.8), P = 0.039. CONCLUSION: Neoadjuvant therapy-related toxicity is common and can have serious consequences including failure to complete chemotherapy cycles, a higher risk of not proceeding to surgical resection and poorer overall survival. Efforts should be made to reduce toxicity and research should aim to identify responders and factors predictive of toxicity.

Sleeve gastrectomy versus Roux-en-Y gastric bypass for type 2 diabetes and morbid obesity: double-blind randomised clinical trial protocol.

INTRODUCTION: Type 2 diabetes (T2D) in association with obesity is an increasing disease burden. Bariatric surgery is the only effective therapy for achieving remission of T2D among those with morbid obesity. It is unclear which of the two most commonly performed types of bariatric surgery, laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), is most effective for obese patients with T2D. The primary objective of this study is to determine whether LSG or LRYGB is more effective in achieving HbA1c<6% (<42 mmol/mol) without the use of diabetes medication at 5 years. METHODS AND ANALYSIS: Single-centre, double-blind (assessor and patient), parallel, randomised clinical trial (RCT) conducted in New Zealand, targeting 106 patients. Eligibility criteria include age 20-55 years, T2D of at least 6 months duration and body mass index 35-65 kg/m(2) for at least 5 years. Randomisation 1:1 to LSG or LRYGB, used random number codes disclosed to the operating surgeon after induction of anaesthesia. A standard medication adjustment schedule will be used during postoperative metabolic assessments. Secondary outcomes include proportions achieving HbA1c<5.7% (39 mmol/mol) or HbA1c<6.5% (48 mmol/mol) without the use of diabetes medication, comparative weight loss, obesity-related comorbidity, operative complications, revision rate, mortality, quality of life, anxiety and depression scores. Exploratory outcomes include changes in satiety, gut hormone and gut microbiota to gain underlying mechanistic insights into T2D remission. ETHICS AND DISSEMINATION: Ethics approval was obtained from the New Zealand regional ethics committee (NZ93405) who also provided independent safety monitoring of the trial. Study commenced in September 2011. Recruitment completed in October 2014. Data collection is ongoing. Results will be reported in manuscripts submitted to peer-reviewed journals and in presentations at national and international meetings. TRIAL REGISTRATION NUMBERS: ACTRN12611000751976, NCT01486680; Pre-results.

Pelvic orientation for total hip arthroplasty in lateral decubitus: can it be accurately measured?

INTRODUCTION: During total hip arthroplasty (THA), accurately predicting acetabular cup orientation remains a key challenge, in great part because of uncertainty about pelvic orientation. This pilot study aimed to develop and validate a technique to measure pelvic orientation; establish its accuracy in the location of anatomical landmarks and subsequently; investigate if limb movement during a simulated surgical procedure alters pelvic orientation. METHODS: The developed technique measured 3-D orientation of an isolated Sawbone pelvis, it was then implemented to measure pelvic orientation in lateral decubitus with post-THA patients (n = 20) using a motion capture system. RESULTS: Orientation of the isolated Sawbone pelvis was accurately measured, demonstrated by high correlations with angular data from a coordinate measurement machine; R-squared values close to 1 for all pelvic axes. When applied to volunteer subjects, largest movements occurred about the longitudinal pelvic axis; internal and external pelvic rotation. Rotations about the anteroposterior axis, which directly affect inclination angles, showed >75% of participants had movement within ±5° of neutral, 0°. CONCLUSIONS: The technique accurately measured orientation of the isolated bony pelvis. This was not the case in a simulated theatre environment. Soft tissue landmarks were difficult to palpate repeatedly. These findings have direct clinical relevance, landmark registration in lateral decubitus is a potential source of error, contributing here to large ranges in measured movement. Surgeons must be aware that present techniques using bony landmarks to reference pelvic orientation for cup implantation, both computer-based and mechanical, may not be sufficiently accurate.

Surgical versus Ponseti approach for the management of CTEV: a comparative study.

BACKGROUND: Results from a comparative study of Ponseti versus surgical management for congenital talipes equino varus (CTEV), using historically managed patients, are presented. No bias existed in terms of management choice or participants recruited. METHODS: Twenty-three surgically treated children (31 club feet; mean age 9.1 y) and 29 treated by the Ponseti technique (42 club feet; mean age 6.5 y) agreed to participate in the study. Twenty-six typically developing children (mean age 7.9 y) were also recruited as a control group. A physical examination and 3-dimensional gait analyses were carried out on all participants, and each child and his/her parent also, independently, completed the Oxford Ankle Foot Questionnaire (OxAFQ). RESULTS: The Ponseti group underwent fewer joint-invasive procedures than the surgical group. Passive range of dorsiflexion and plantarflexion were significantly less in the CTEV groups when compared with the control group (P<0.001), and plantarflexion was also significantly less in the surgical than in the Ponseti group (P<0.05). The bimalleolar axis was found to be significantly less in the CTEV groups than in the control group (P<0.001) and also significantly less in the surgical than in the Ponseti group (P<0.05). The gait deviation index, a gait score based on kinematics, showed a more normal gait pattern in the Ponseti group compared with the surgical group (P<0.001). The CTEV groups did not differ significantly from each other in terms of ankle sagittal and transverse plane kinematics or kinetics, but foot progression angle for the Ponseti group was external, whereas that for the surgical group was internal. The Ponseti group also scored higher than the surgical group in terms of patient satisfaction, with significantly better parent-rated OxAFQ scores in the "emotional" and "school and play" domains. CONCLUSIONS: The adoption of the Ponseti technique has resulted in fewer and less-invasive operations for our CTEV population, with accompanying improvement in the overall gait pattern (gait deviation index) and parent satisfaction (OxAFQ). LEVEL OF EVIDENCE: Level III.

Detection of asymptomatic adenocarcinoma at endoscopy prior to gastric banding justifies routine endoscopy.

BACKGROUND: Pre-operative upper gastrointestinal (GI) endoscopy prior to gastric banding surgery remains controversial. We report the finding of asymptomatic oesophageal adenocarcinomas detected at pre-operative endoscopy in our unit. METHODS: Data from a prospectively maintained database concerning the period May 2003 to October 2010 were reviewed. We identified 371 patients who had undergone upper GI endoscopy prior to gastric banding. Endoscopy reports were reviewed to identify any pathology detected. RESULTS: Endoscopy revealed abnormalities in 207 (56%) patients. A range of abnormalities were detected, the most significant of which were two asymptomatic oesophageal adenocarcinomas. CONCLUSIONS: The detection of two early, asymptomatic oesophageal adenocarcinomas in a high risk patient group justifies our policy of routine upper GI endoscopy prior to gastric banding surgery.

Electronic nose analysis of bronchoalveolar lavage fluid.

BACKGROUND: Electronic nose (E-nose) technology has been successfully used to diagnose a number of microbial infections. We have investigated the potential use of an E-nose for the diagnosis of ventilator-associated pneumonia (VAP) by detecting micro-organisms in bronchoalveolar lavage (BAL) fluid in a prospective comparative study of E-nose analysis and microbiology. MATERIALS AND METHODS: BAL samples were collected using a blind technique from 44 patients following a minimum of 72 h mechanical ventilation. Control samples were collected from six patients mechanically ventilated on the intensive care unit (ICU) immediately following elective surgery. Quantitative microbiological culture and E-nose headspace analysis of the BAL samples were undertaken. Multivariate analysis was applied to correlate E-nose response with microbiological growth. RESULTS: E-nose fingerprints correctly classified 77% of the BAL samples, with and without microbiological growth from patients not on antibiotics. Inclusion of patients on antibiotics resulted in 68% correct classification. Seventy per cent of isolates, cultured in the laboratory from the clinical samples, were accurately discriminated into four clinically significant groups. CONCLUSIONS: E-nose technology can accurately discriminate between different microbial species in BAL samples from ventilated patients on ICU at risk of developing VAP with accuracy comparable with accepted microbiological techniques.

Functional characterization of Synechocystis sp. strain PCC 6803 pst1 and pst2 gene clusters reveals a novel strategy for phosphate uptake in a freshwater cyanobacterium.

Synechocystis sp. strain PCC 6803 possesses two putative ABC-type inorganic phosphate (P(i)) transporters with three associated P(i)-binding proteins (PBPs), SphX (encoded by sll0679), PstS1 (encoded by sll0680), and PstS2 (encoded by slr1247), organized in two spatially discrete gene clusters, pst1 and pst2. We used a combination of mutagenesis, gene expression, and radiotracer uptake analyses to functionally characterize the role of these PBPs and associated gene clusters. Quantitative PCR (qPCR) demonstrated that pstS1 was expressed at a high level in P(i)-replete conditions compared to sphX or pstS2. However, a P(i) stress shift increased expression of pstS2 318-fold after 48 h, compared to 43-fold for pstS1 and 37-fold for sphX. A shift to high-light conditions caused a transient increase of all PBPs, whereas N stress primarily increased expression of sphX. Interposon mutagenesis of each PBP demonstrated that disruption of pstS1 alone caused constitutive expression of pho regulon genes, implicating PstS1 as a major component of the P(i) sensing machinery. The pstS1 mutant was also transformation incompetent. (32)P(i) radiotracer uptake experiments using pst1 and pst2 deletion mutants showed that Pst1 acts as a low-affinity, high-velocity transporter (K(s), 3.7 + or - 0.7 microM; V(max), 31.18 + or - 3.96 fmol cell(-1) min(-1)) and Pst2 acts as a high-affinity, low-velocity system (K(s), 0.07 + or - 0.01 microM; V(max), 0.88 + or - 0.11 fmol cell(-1) min(-1)). These P(i) ABC transporters thus exhibit differences in both kinetic and regulatory properties, the former trait potentially dramatically increasing the dynamic range of P(i) transport into the cell, which has potential implications for our understanding of the ecological success of this key microbial group.

Test-retest reliability of a 1-min walk test in children with bilateral spastic cerebral palsy (BSCP).

The test-retest reliability of a 1-min walk test at a child's maximum walking speed was assessed in children with bilateral spastic cerebral palsy (BSCP). Twelve male and five female children (age range 3-18 years, mean age 12 years 8 months) participated in the study. Children were classified as GMFCS level I (n=5), level II (n=8) and level III (n=4). Results showed that for walk tests performed on different days, distances varied by no more than 13.1m (for 95% of participants) and that a practice walk was vital for reducing systematic bias. The intraclass correlation coefficient was 0.94. A 1-min walk test is a reliable method of assessing function in children with CP but care must be taken when interpreting changes in individual patient data.

The influence of wear paths produced by hip replacement patients during normal walking on wear rates.

Variation in wear paths is known to greatly affect wear rates in vitro, with multidirectional paths producing much greater wear than unidirectional paths. This study investigated the relationship between multidirectional motion at the hip joint, as measured by aspect ratio, sliding distance, and wear rate for 164 hip replacements. Kinematic input from three-dimensional gait analysis was used to determine the wear paths. Activity cycles were determined for a subgroup of 100 patients using a pedometer study, and the relationship between annual sliding distance and wear rate was analyzed. Poor correlations were found between both aspect ratio and sliding distance and wear rate for the larger group and between annual sliding distance and wear rate for the subgroup. However, patients who experienced a wear rate <0.08 mm/year showed a strong positive correlation between the combination of sliding distance, activity levels, and aspect ratio and wear rate (adjusted r(2) = 55.4%). This group may represent those patients who experience conditions that most closely match those that prevail in simulator and laboratory tests. Although the shape of wear paths, their sliding distance, and the number of articulation cycles at the hip joint affect wear rates in simulator studies, this relationship was not seen in this clinical study. Other factors such as lubrication, loading conditions and roughness of the femoral head may influence the wear rate.

Comparison of immediate postoperative walking ability in patients receiving minimally invasive and standard-incision hip arthroplasty: a prospective blinded study.

Minimally invasive hip arthroplasty is thought to result in less soft tissue damage, earlier ambulation, and improved rehabilitation. This prospective blinded cohort study objectively analyzed early functional walking ability by stride analysis 2 days postoperatively. Ninety-five patients were analyzed, 43 of who received the minimal incision and 52 the traditional incision. Patients, physiotherapists, and assessors were blinded to the incision used. Velocity, cadence, stride length, operated and nonoperated limb step-length, and the ratio of step length of the operated to nonoperated limbs were recorded. No significant differences in any of these variables were shown between the minimal-incision and traditional-incision groups. This study demonstrates no functional benefits of the minimally invasive incision over the standard one in terms of early walking ability.