Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia.

INTRODUCTION: There are limited data regarding long-term outcomes after surgical repair of giant paraoesophageal hiatus hernia (GPHH). The aim of this study was to assess symptomatic recurrence and patient-reported outcomes following GPHH repair. METHODS: 178 patients undergoing elective (127) and emergency (51) GPHH repair between 1994 and 2015 were identified from the prospectively collected Lothian Surgical Audit database. Electronic patient records were used to determine rate of clinical recurrence. A postal questionnaire was used to assess modified DeMeester, 'Gastrointestinal Symptom Rating Scale' symptom scores, breathing and exercise tolerance, and patient satisfaction. RESULTS: Median follow-up was 35 months (range 12-238). 15 (8.4%) patients developed a clinical recurrence and 13 (7.3%) underwent a further operation. The clinical recurrence rates were similar in patients followed-up less than 5 years and beyond 5 years [10/128 (7.8%) vs 5/50 (10%)]. Mortality rate was 1.6% for elective compared with 16.7% for emergency procedures (P < 0.001). Completed questionnaires were received from 95 (78.5%) of 121 eligible patients. Mean symptom scores were low (Modified DeMeester 2.6). 83.7% of patients reported a good or excellent outcome, and 97.8% believed they had made the correct decision to undergo surgery. CONCLUSIONS: Surgical repair of GPHH is associated with high levels of patient satisfaction and good overall symptom outcome. There is a clinical recurrence rate of 8.4%, which does not significantly increase with long-term follow-up.

A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy.

INTRODUCTION: There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG. METHODS: A prospective study of patients undergoing LSG (2014-2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively. RESULTS: Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months). CONCLUSION: GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.

Aspiration and allograft injury secondary to gastroesophageal reflux occur in the immediate post-lung transplantation period (prospective clinical trial).

OBJECTIVES: To provide novel pilot data to quantify reflux, aspiration, and allograft injury immediately post-lung transplantation. BACKGROUND: Asymptomatic reflux/aspiration, associated with allograft dysfunction, occurs in lung transplant recipients. Early fundoplication has been advocated. Indications for surgery include elevated biomarkers of aspiration (bile salts) in bronchoalveolar lavage fluid (BALF). Measurements have been mostly documented after the immediate posttransplant period. We report the first prospective study of reflux/aspiration immediately posttransplantation to date. METHODS: Lung transplant recipients were recruited over 12 months. At 1 month posttransplantation, patients completed a Reflux Symptom Index questionnaire and underwent objective assessment for reflux (manometry and pH/impedance). Testing was performed on maintenance proton pump inhibitor. BALF was assessed for pepsin, bile salts, interleukin-8 and neutrophils. RESULTS: Eighteen lung transplant recipients, median age of 46 years (range: 22-59 years), were recruited. Eight of 18 patients had abnormal esophageal peristalsis. Five of 17 patients were positive on Reflux Symptom Index questionnaire. Twelve of 17 patients had reflux. Three patients exclusively had weakly acid reflux. Median acid exposure was 4.8% (range: 1%-79.9%) and median esophageal volume exposure was 1.6% (range: 0.7-5.5). There was a median of 72 reflux events (range: 27-147) per 24 hours. A correlation existed between Reflux Symptom Index score and proximal reflux (r = 0.533, P = 0.006). Pepsin was detected in 11 of 15 BALF samples signifying aspiration (median: 18 ng/mL; range: 0-43). Bile salts were undetectable, using spectrophotometry and rarely detectable using dual mass spectrometry (2/15) (levels 0.2 and 1.2 µmol/L). Lavage interleukin-8 and neutrophil levels were elevated. A correlation existed between proximal reflux events and neutrophilia (r = 0.52, P = 0.03). CONCLUSIONS: Lung transplant recipients should be routinely assessed for reflux/aspiration within the first month posttransplant. Reflux/aspiration can be present early postoperatively. Pepsin was detected suggesting aspiration. Bile salts were rarely detected. Proximal reflux events correlated with neutrophilia, linked to allograft dysfunction and mortality. These results support the need for early assessment of reflux/aspiration, which may inform fundoplication.

A Systematic Review of Patient and Public Involvement (PPI) in Bariatric Research Trials: The Need for More Work.

Patient and public involvement (PPI) has gained increased attention in research circles. The consistency of PPI reporting has been addressed by the development of validated checklists such as GRIPP and GRIPP2. The primary aim of this study was to identify the incidence of PPI reporting in bariatric research. MEDLINE/PubMed, EMBASE, and CINAHL/Cochrane databases were searched for publications between 1st January 2018 to 31st December 2021 for "bariatric surgery" OR "weight loss surgery" OR "obesity surgery" AND "randomized controlled trials." Ninety studies fulfilled exclusion criteria; two studies reported direct PPI involvement, one indirectly used PPI and one reported not using PPI methods. No other study made direct or indirect mention of PPI. Concluding, that GRIPP2 and PPI reporting in bariatric surgery trials is lacking.

Mirizzi syndrome complicating an anomalous biliary tract: a novel cause of a hugely elevated CA19-9.

A 71-year-old man presented with painful obstructive jaundice, weight loss and an elevated CA19-9 (>16,000 U/ml) (normal levels <39 U/ml). Imaging showed a hilar mass. After biliary stenting, the CA19-9 returned to normal. At surgery, biliary obstruction owing to a gallstone (Type II Mirizzi) was found to be complicating a congenital biliary tract anomaly. The obstructing stone was removed and the anomalous biliary tract reconstructed with a Roux-en-y loop, and the patient made an uneventful recovery and remained normal over a 2-year follow-up. A Type II Mirizzi with a biliary tract anomaly is an undocumented cause of an elevated CA19-9. The possibility of benign disease must be considered even with very high levels of the cancer marker CA19-9 or the opportunity for curative surgery may be missed.

Isolated venous thrombosis: a new cause of acute graft failure in a non-piggyback liver transplant (case report).

A 46-year-old man was re-transplanted using standard technique for hepatic arterial thrombosis one month following orthotopic liver transplant. Postoperatively he deteriorated acutely with hypotension and disseminated intravascular coagulation. Angiography demonstrated a patent hepatic artery, portal vein and inferior vena cava but isolated thromboses in the right and middle hepatic veins. He was treated with transvenous intrahepatic porto-systemic shunt but subsequently died from sepsis and multiorgan failure. This vascular complication in the absence of outflow stenosis and with a normal prothrombotic screen is a previously undocumented cause of acute graft failure in a standard transplant without retrohepatic vena caval preservation. We present our case and discuss the relevant literature.

Long-term outcomes following laparoscopic anterior and Nissen fundoplication.

BACKGROUND: Limited evidence exists to which operation gives best long-term outcomes for gastro-oesophageal reflux disease. This study aimed to assess long-term symptomatic outcome and satisfaction following laparoscopic anterior (LA) or Nissen fundoplication in a specialist upper gastrointestinal unit. METHODS: Patients who underwent primary LA or Nissen (LN) fundoplication between May 1994 and June 2010 were identified from a prospectively collected database. DeMeester, modified DeMeester, 'Gastrointestinal Symptom Rating Scale' scores and patient satisfaction were assessed by questionnaire. RESULTS: A total of 387 patients underwent surgery and 246 patients (65%) completed questionnaires, with 181 LA patients and 65 LN patients. Median follow-up was 83 months for LA and 179 months for LN (P < 0.001). A total of 218/245 (89%) reported major improvement in symptoms and 27 (11%) reported poor outcomes. There was no differences between LA and LN for symptom scores at short (<5 years) or long-term follow-up (>5 years). Women reported significantly higher DeMeester scores and lower satisfaction (P = 0.012). One hundred and eighteen (48%) patients were taking proton pump inhibitors (PPI) at follow-up despite high satisfaction rates. CONCLUSION: LA and LN have similar long-term results with patients reporting high satisfaction levels. Women reported more symptoms and less satisfaction than men. Despite high satisfaction rates a high percentage of patients take PPIs.

Barrett's adenocarcinoma 52 years after subtotal esophagectomy for pediatric peptic stricture.

Barrett's esophagus results from the long-term effects of both acid and bile reflux. After subtotal esophagectomy and reconstruction with a gastric tube, many patients experience profound reflux. Development of Barrett's epithelium in the esophageal remnant has been reported. Here we report the case of a man who was diagnosed with adenocarcinoma in his esophageal remnant on a background of Barrett's change 52 years after undergoing one of the first esophageal resections for benign disease as a child.

Lung transplantation, gastroesophageal reflux, and fundoplication.

Lung transplantation is an accepted treatment strategy for end-stage lung disease; however, bronchiolitis obliterans syndrome is a major cause of morbidity and mortality. This review explores the role of gastroesophageal reflux disease in bronchiolitis obliterans syndrome and the evidence suggesting the benefits of anti-reflux surgery in improving lung function and survival. There is a high prevalence of gastroesophageal reflux in patients post lung transplantation. This may be due to a high preoperative incidence, vagal damage and immunosuppression. Reflux in these patients is associated with a worse outcome, which may be due to micro-aspiration. Anti-reflux surgery is safe in selected lung transplant recipients; however there has been one report of a postoperative mortality. Evidence is conflicting but may suggest a benefit for patients undergoing anti-reflux surgery in terms of lung function and survival; there are no controlled studies. The precise indications, timing, and choice of fundoplication are yet to be defined, and further studies are required.

A call for standardization of antireflux surgery in the lung transplantation population.

Long-term survival post lung transplant is reduced significantly by Bronchiolitis Obliterans Syndrome. It is suggested that extra-esophageal reflux disease is a risk factor for Bronchiolitis Obliterans Syndrome and that antireflux surgery may be beneficial. However, practice between centers varies greatly. We suggest a need for improved evidence and standardization.

Use of buccal myomucosal flap in secondary cleft palate repair.

BACKGROUND: The purpose of this study was to assess the effectiveness of the buccal myomucosal flap in secondary repairs of cleft palate. METHODS: Twenty-two patients who underwent secondary palatoplasty between 1989 and 2004 in which a buccal myomucosal flap was used were reviewed retrospectively. All patients had undergone at least one previous attempted repair at other institutions. Indications for the secondary repair included velopharyngeal incompetence and/or oronasal fistula. Patients were evaluated preoperatively for oronasal fistula status, velopharyngeal competence, nasal resonance, speech quality, and nasal escape. RESULTS: The buccal myomucosal flap was used in all patients. The patients' mean age was 8.5 years (range, 1 to 23 years). Correction was indicated in seven patients with velopharyngeal incompetence (32 percent), five patients with oronasal fistulas (23 percent), and 10 patients with both conditions (45 percent). Preoperative assessment revealed four patients (18 percent) with an associated syndrome, 17 of 20 patients with hyperresonance (85 percent), 16 of 20 patients with nasal escape (80 percent), and 12 of 20 patients with poor speech (60 percent). The buccal myomucosal flap technique was used alone in 50 percent of patients, six patients had a staged correction (27 percent) and five patients required multiple procedures (23 percent). All fistulas remained closed. Two patients showed mild velopharyngeal incompetence (p = 0.001) and two patients continued to display hyperresonance (p < 0.001). Speech quality improved to a good level in 17 patients (77 percent) (p < 0.001). CONCLUSION: Palate re-repair combined with a buccal myomucosal flap, occasionally in conjunction with other techniques, is an effective method for correcting failed cleft palate repairs.

An analysis of risk factors associated with failure of below knee amputations.

BACKGROUND: Below knee amputation (BKA) is often required in patients with critical limb ischemia. When such a procedure fails, an above knee revision (AKA) is required. This can cause further complications in this group of patients, who already have a high incidence of medical co-morbidities. METHODS: Case records of 47 patients (51 procedures performed) with BKA for peripheral vascular diseases during a 4-year period were reviewed. Clinical factors were analyzed using bi- and multi-variate analysis against the procedure outcome. Degree of social deprivation was evaluated with DEPCAT score in relation to amputation failure. Each arterial segment of the pre-operative arteriograms was scored based on a 3-point scoring system (0=normal, 1=stenosis, and 2=cclusion). With the assignment of an arbitrary weight for each segment, a total arterial score (TAS) was derived for each patient. RESULTS: Eighteen percent of BKA (n=9) failed. Absence of popliteal pulse (failure vs. success: 100% vs. 63%, P=0.04), calf rest pain (67% vs. 20%, P=0.01), combination of calf rest pain and feet tissue loss (CRPFTL; 67% vs. 3%, P=0.00), postoperative stump trauma (44% vs. 10%, P=0.03), and wound infection (WI; 89% vs. 26%, P=0.00) were factors associated with the failure of a BKA in bivariate analysis. Using multiple logistic regression, WI (OR=14) and CRPFTL (OR=47) were found to be independent predictors for the outcome of BKA. No statistical significance was found between the DEPCAT score and the failure rate. TAS was significantly higher in the failure group (median=17 vs. 9; P=0.00). CONCLUSIONS: This study suggests that CRPFTL and postoperative WI are predictor variables for the failure of a BKA. In addition, there is the potential role of arteriogram scoring in predicting the outcome of a BKA.