Patient-reported outcomes after oesophagectomy in the multicentre LASER study.

BACKGROUND: Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life. METHODS: This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models. RESULTS: Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms. CONCLUSION: A long-term symptom burden is common after oesophageal cancer surgery.

Routine use of feeding jejunostomy in oesophageal cancer resections: results of a survey in England.

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40 units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken.

Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying.

Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.

Short-term outcomes after Ivor Lewis oesophagectomy for cancer during the COVID-19 pandemic.

INTRODUCTION: Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. METHODS: We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24-48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. RESULTS: Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. CONCLUSIONS: ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.

An inguinal hernia that was not meant to be: a female with seminoma.

Complete androgen insensitivity is a rare X-linked disorder characterised by a female phenotype in a chromosomally male individual. It usually presents at puberty with primary amenorrhoea or as an inguinal mass in a female infant. Treatment includes bilateral orchidectomy and hormone replacement therapy. We present the case of a 31-year-old female with complete androgen insensitivity and a presumed inguinal hernia. We discuss the importance of early diagnosis, emphasise the consequences of misdiagnosis, and raise the question of whether such patients have been appropriately managed in the past.

Impact of age extension to include 47-49 year old women on the workload of the surgical department of a single Breast Cancer Screening Unit--The first non-randomized experience in UK.

INTRODUCTION: The aim of this study was to assess the impact on the surgical unit of the first year (prevalence screening) of non-randomized invitations to 47-49 year old women for breast screening, from a single breast screening unit. METHODS: All women undergoing surgery in the age group 47-49 years, referred via screening were identified and the increased workload analysed. RESULTS: 4250 (76%) women were screened of the 5624 invited. 396 women were recalled, of whom 88 (22%) underwent a core biopsy. 32 patients required surgical intervention. 20 patients (62.5%) were confirmed to have either DCIS (6 patients) or invasive malignancy (14 patients). They required 37 theatres attendances requiring 42 operations. 16 wire guided wide local excisions (14 with sentinel node biopsy), 7 mastectomies (2 with sentinel node biopsy; 1 with axillary clearance), 6 margin re-excisions, 1 tissue expander insertion and removal, 3 Latissimus Dorsi with implant and 2 TRAM reconstructions. Other cases include haematoma drainage, scar revisions and nipple reconstructions. This group generated 100 NHS surgical outpatient consultations (78 breast and 22 plastic surgery). 12 patients (37.5%) underwent surgery for a B3 vacuum result; 10 underwent wire guided and 1 ultrasound guided skin marked excision biopsy. 1 patient was treated privately. This group generated 25 NHS surgical outpatients consultations. CONCLUSIONS: This study highlights the impact of the 47-49 year age extension within the breast screening programme on the workload of the surgical department of a UK Breast Cancer Screening Unit offering non-randomized invitations. The study will inform other surgical units of expected workload when age extension is fully implemented.

Need for standardization of the measurement of preoperative weight in bariatric surgical patients in the UK: A survey of British Obesity and Metabolic Surgery Society (BOMSS) members.

BACKGROUND: Weight loss is the most commonly used metric in comparing outcomes after bariatric surgery. This is frequently presented in the form of percentage of excess weight loss (%EWL). Patients' weight is measured at several time points prior to surgery. The time point selected as the preoperative weight can have significant effects upon the measurement of %EWL. This study aimed to investigate whether there was any standardization in the selection of preoperative weight amongst UK bariatric surgery healthcare professionals. METHODS: A questionnaire survey was conducted among the delegates at the British Obesity and Metabolic Surgery Society (BOMSS) meeting in January 2011. RESULTS: A total of 54 delegates (consultant & trainee surgeons, bariatric specialist nurses, dieticians and psychologists) responded to the survey. A wide variation was noted in which preoperative weight was used in the calculation of %EWL, both among various disciplines and also among the same disciplines. The majority (61%) used the preoperative weight recorded at the bariatric surgical assessment clinic prior to surgery. 20% of delegates used the highest recorded preoperative weight. The remainder of delegates used weight recorded on the day of surgery (17%) or the weight recorded during the first visit to a medical physician led weight management clinic (2%). CONCLUSION: Variation in the measurement of the preoperative weight will lead to variations of calculated %EWL between different bariatric units or even between different disciplines in the same unit. This will make comparison of published outcome data difficult. This study highlights the urgent need for standardization.

Enterobius vermicularis infestation of the appendix and management at the time of laparoscopic appendectomy: case series and literature review.

INTRODUCTION: Enterobius vermicularis infestation of the vermiform appendix can mimic appendicitis. In these cases, laparoscopic appendicectomy runs a risk of contamination of the peritoneal cavity with worms. We reviewed our practice to suggest changes that will reduce the release of worms and propose methods to use in case contamination occurs. METHODS: 498 patients underwent appendicectomy over a sixty-three month period. 13 (2.6%) patients had confirmed E. vermicularis on histology of whom 6 (46%) were performed laparoscopically. These patients' case notes were retrospectively reviewed. RESULTS: The worms were noted intra-operatively during the laparoscopic appendectomies. In 2 cases, where peritoneal cavity contamination with worms occurred, they were dealt with careful diathermy or endoscopic suction. In the other cases, contamination was avoided by simple measures including division of the appendix in a staggered manner whilst maintaining traction, removal of worms using endoscopic suction or diathermy and quick transfer to a specimen bag. CONCLUSION: We highlight that the symptoms of appendicitis can be due to Enterobius vermicularis infestation without any histological evidence of acute inflammation. Surgeons need to be aware of this possibility during laparoscopic appendicectomy and simple techniques can minimise the risk of contamination. It also enables early diagnosis and treatment without awaiting histological findings.