Delayed Gastric Emptying Following Laparoscopic Repair of Very Large Hiatus Hernias Impairs Quality of Life.

BACKGROUND: Delayed gastric emptying (DGE) following hiatus hernia surgery may affect a substantial number of patients with adverse clinical consequences. Here, we aim to evaluate the impact of DGE following laparoscopic repair of very large hiatus hernias on patients' quality of life, gastrointestinal symptomatology, and daily function. METHODS: Analysis of data collected from a multicenter prospective randomised trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (>50% of stomach in chest). DGE was defined as gastric food retention visualised at endoscopy after 6 h of fasting at 6 months post-surgery. Quality of life (QOL), gastrointestinal symptomatology, and daily function were assessed with the SF-36 questionnaire, Visick scoring and structured surveys administered prior to surgery and at 1, 3, 6 and 12 months after surgery. RESULTS: Nineteen of 102 (18.6%) patients had DGE 6 months after surgery. QOL questionnaires were completed in at least 80% of patients across all time points. Compared with controls, the DGE group demonstrated significantly lower SF-36 physical component scores, delayed improvement in health transition, more adverse gastrointestinal symptoms, higher Visick scores and a slower rate of return to normal daily activities. These differences were still present 12 months after surgery. CONCLUSIONS: DGE following large hiatus hernia repair is associated with a negative impact on quality of life at follow-up to 12 months after surgery.

Dangers of a single pellet.

Recent figures suggest gun violence in New Zealand is on the rise. Between 6,000 and 8,000 shotguns are imported annually. The challenge specific to managing shotgun injury is the wide field of damage caused by multiple pellets. It is easy to overlook a single pellet when assessing a patient with distracting injuries. This case highlights this lesson and the significant injury that can arise from a single pellet.

Blind Pouch Syndrome in Gastrojejunostomy.

Blind pouch syndrome is a rare complication of a gastrojejunostomy. Its presentation may differ from blind pouches at other locations in that a small pouch can cause significant symptoms of mechanical obstruction before it is large enough to develop bacterial overgrowth. The effect of a small pouch may be overlooked at endoscopy and a high clinical index of suspicion is required. Here we present a case report of Gastrojejunostomy Blind Pouch Syndrome to highlight this clinically distinct entity.

Use of autopsy in general surgery: a comparison of practice and opinion.

OBJECTIVE: To examine current practice regarding autopsy requests and assess consultant opinion regarding the role of autopsy in a general surgical department. METHODS: One hundred deaths that occurred in a teaching hospital general surgical department, over a 2-year period, were randomly selected. After review of the hospital notes, a brief summary of each admission was distributed to all 13 consultant general surgeons in the department. Surgeons were asked to comment whether each case should have been discussed with the coroner, whether a coroner's autopsy should have been carried out, whether a hospital post-mortem examination should have been carried out and whether it would be appropriate to complete a death certificate without a post-mortem examination. Surgeon responses were compared with actual outcomes, and both were analysed for predictors of variation in practice. RESULTS: The majority of patients were elderly (median age 79 years, 49% >80 years), were admitted acutely (92%) and did not undergo an operation (73%). Thirty-three patients died of cardiac or respiratory causes. Patients who had undergone a recent operation were more likely to be referred to the coroner (P < 0.001) and more likely to undergo coroner's autopsy (P = 0.011). Older patients and those admitted from a rest home were less likely to be referred to the coroner (P < 0.001 and 0.02, respectively) or undergo coroner's autopsy (P = 0.002 and 0.011, respectively). The survey predicted more referrals to the coroner (44 vs 30, P = 0.001) and more hospital autopsies (21 vs 2, P < 0.001) and that the treating doctor would complete the certificate of death less often than actually happened (79 vs 91, P = 0.004). The survey suggested that surgeons were more likely to complete the certificate of death in patients with active malignancy (P = 0.01), but this was not observed in practice. CONCLUSIONS: General surgeons consider autopsy to be necessary more often than that is taking place in practice in our institution. The continued decline in autopsy rates may compromise the safety and quality of the service provided by general surgeons and result in a gap in the education of surgeons and trainees.

Reinterpretation of radiological findings in oesophago-gastric multidisciplinary meetings.

BACKGROUND: This study aims to objectively evaluate the clinical impact and significance of the multidisciplinary team meeting (MDT) in the management of oesophago-gastric malignancies in a tertiary institution. METHODS: A prospective observational study was designed to examine the role of MDT in the interpretation of computerized tomography (CT) scans in oesophago-gastric malignancies. The MDT reporting of CT scans were compared with the 'pre-meeting' formal report of the scans. 'Pre-meeting' CT reports are provided by internal institutional or independent radiologist. The frequency and significance of any reporting variance is examined. RESULTS: Of the 34 patients discussed, 13 patients (38%) had variations to the formal radiological report. This led a modification of disease stage in seven patients (21%) and change in diagnosis in three patients (9%). This had a major impact in nine patients (26%) of which seven patients (24%) had modification in treatment as a result of imaging reinterpretation. CONCLUSION: This study provides preliminary quantative evidence of the utility and importance of the MDT process in the management of oesophago-gastric malignancies. This has potential significant implications for basing patient treatment on isolated reports outside of MDT and supports this process as a standard of care.

The importance of anatomy in a new iatrogenic disease: yttrium microsphere-induced gastritis.

We describe a patient who underwent selective interventional radiation therapy (SIRT) for inoperable colorectal cancer liver metastases and who developed gastritis as a direct result. The Yttrium microspheres are seen in the biopsy. The anatomical basis for the complication is presented. New treatments result in new iatrogenic complications.

Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation.

BACKGROUND: Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia. MATERIALS AND METHODS: Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments. RESULTS: Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score. CONCLUSIONS: Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.

Cholecystectomy following acute presentation to a major New Zealand metropolitan hospital: change to the timing of surgery is needed.

AIMS: To review the management and outcome of patients presenting with acute biliary pain/cholecystitis, mild acute pancreatitis, or cholangitis to a major New Zealand (NZ) metropolitan hospital. METHODS: A retrospective case note review was performed for all patients admitted acutely to Christchurch Public Hospital between 1 February 2005 and 31 September 2005, with the diagnosis of acute biliary pain/acute cholecystitis, acute pancreatitis, or cholangitis. Basic demographics, inpatient management, and subsequent outcome were recorded. RESULTS: Sixty-eight (65%) patients were admitted with acute biliary pain/cholecystitis, 23 (22%) with mild acute pancreatitis, and 13 (13%) with cholangitis. Twelve of 81 (15%) patients (who were suitable for index cholecystectomy) underwent surgery, including only 3 of the 18 patients with mild acute pancreatitis. In the remaining 69 (85%) patients, who were eligible but did not undergo cholecystectomy at the index admission, 29 (42%) subsequently represented to the emergency department. Forty-eight (70%) patients required further inpatient admission related to gallstone-related pathology within the study period. Subsequently, 42 (61%) of the 69 patients treated conservatively underwent cholecystectomy at a median (range) of 70 (1-195) days from index admission, including 6 emergency cholecystectomies due to re-presentation CONCLUSIONS: The management of acute gallstone-related disease at a major NZ metropolitan hospital fails to meet with current international standards. Few patients undergo index cholecystectomy, and a large proportion of those treated conservatively return to the health sector with ongoing problems.