Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review.

Background: The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness. Methods: A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA. Results: Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn. Conclusions: We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.

A Cautionary Tale: A Case Report Describing a Benign Parotid Oncocytoma Diagnosed as Metastatic Squamous Cell Carcinoma on Fine Needle Aspirate.

Parotid oncocytoma is a rare salivary gland tumour. Management does not require surgical intervention if diagnosed on a preoperative biopsy. A 64-year-old man presented with a parotid mass diagnosed as mcSCC on fine-needle aspiration cytology (FNAC). Surgical histopathology following parotidectomy demonstrated an oncocytoma of the parotid gland. Parotid oncocytomas are rare; therefore, diagnosis can be difficult. An MRI, CT, and US-guided biopsy are required for diagnosis. Ultrasound-guided core biopsy (UGSB) is more sensitive and specific when compared to FNAC for diagnosing malignant tumours. Diagnoses of benign salivary gland tumours on biopsy remain challenging. The aim of this article is to highlight the difficulty of diagnosing salivary gland tumours. We further aim to outline the contributing features that lead to this misdiagnosis and suggest steps to circumvent it in the future. This report describes the challenges in diagnosing salivary gland tumours and outlines the contributing features of this misdiagnosis. We add to the literature an additional case of a parotid oncocytoma.

A Rare Case of Small Bowel Obstruction in a Patient with Endosalpingiosis, Fitz-Hugh-Curtis Syndrome, and Chlamydia trachomatis Pelvic Inflammatory Disease.

A 19-year-old female has multiple presentations to emergency department with recurrent abdominal pain. During her third presentation, the radiological features were suggestive of high-grade small bowel obstruction in a virgin abdomen. A diagnostic laparoscopy has been performed. The intraoperative findings include a band adhesion between omentum and small bowel mesentery, and perihepatic adhesions consistent with Fitz-Hugh-Curtis syndrome. The histopathology from a biopsy of the macular lesions of the abdominal wall showed endosalpingiosis. The postoperative high vaginal swab was positive for Chlamydia trachomatis. The underlying cause of her small bowel obstruction could be due to pelvic inflammatory disease, Fitz-Hugh-Curtis syndrome, or endosalpingiosis. We aimed to create awareness amongst readers that small bowel obstruction in young female patients with no prior abdominal surgery is possible and often difficult to diagnose immediately.

Ewing sarcoma: A pictorial review of typical and atypical locations with reference to the updated 2020 WHO classification system.

Ewing sarcoma (ES) is a small round cell sarcoma which usually occurs in the paediatric and young adult age groups. This pictorial review briefly discusses and presents the typical skeletal and extraskeletal locations which ES is encountered, including the metadiaphysis of long bones, pelvis, chest wall and paravertebral regions. Five cases of ES in atypical locations are then presented along with an observation of demographic differences between skeletal and extraskeletal ES. These cases include ES arising from the metatarsal, scapula, breast, intracranial soft tissue and the paranasal sinuses. Presenting symptoms, treatment approach and prognosis are highly variable depending on the location; and multimodal imaging is centrepiece in the management process. Management usually includes any combination of chemotherapy, radiotherapy and surgery. The WHO classification system was updated in 2020 to include some of the rare genetic subtypes of ES. One such case of the BCOR subtype is demonstrated in this review and occurs in an atypical location. Whether these subtypes have distinct radiological features or a propensity to occur in atypical locations is an area for further research.

Rare case report of acalculous cholecystitis: Gallbladder torsion resulting in rupture.

Acalculous cholecystitis caused by gallbladder torsion is a rare condition. Only 500 cases have been reported since the first diagnosed case in 1898. We present the case of a 89-year-old woman with sudden onset of severe epigastric pain, radiating across her right costal margin, associated with nausea. Her abdomen was soft, mildly distended, Murphy's negative but with epigastric tenderness and palpable mass. Computed tomography and ultrasound demonstrated significant acute cholecystitis, with the common bile duct measuring 7 mm. Due to the patients' comorbidities, conservative treatment was initiated, until she was becoming increasing worse, so a laparoscopic cholecystectomy was performed. The operation revealed gallbladder torsion causing complete gallbladder necrosis and perforation with intraperitoneal biliary spillage. Gallbladder torsion should be a high differential if an elderly female patient presenting with sudden onset of abdominal pain, tender epigastric/right upper quadrant mass and a distended gallbladder on imaging. A laparoscopic cholecystectomy must be performed promptly to reduce the likelihood of gallbladder rupture and reduce the mortality and morbidity associated with this condition.

A rare case report of gallbladder carcinosarcoma.

INTRODUCTION: Carcinosarcoma of the gallbladder (CSGB) is a rare clinical condition. To date, only 107 cases of CSGB have been reported worldwide. We present our experience of a late presentation of disseminated CSGB. To this we add a discussion of prognostic factors and treatment options for this rare gallbladder malignancy drawn from CSGB cases reported in the literature. Case report: A 73-year-old female presented to our facility with a poorly differentiated CSGB with widespread liver and peritoneal metastases. Fifteen days from the time of hospital admission, the patient suffered an acute episode of massive haematemesis with clinical signs of perforated viscous. Her cause of death was thought to be a tumour-related duodenal erosion. Discussion: Given the poor prognosis of CSGB, particularly when diagnosed at locally advanced or disseminated stages, we suggest a greater role for laparoscopic tissue diagnosis before considering radical surgical intervention.

Gastric inlet obstruction from oesophageal cancer with internalized gastric band: a worrisome outcome?

Band erosion is one late complication of laparoscopic adjustable gastric banding (LAGB), with the reported incidence between 1% and 28%. Far less common is oesophageal adenocarcinoma after LAGB, with only three cases previously described. Here we report a single case of complete gastric inlet obstruction with oesophageal adenocarcinoma and complete internalization of a gastric band 19 years after its placement.

Supraclavicular flap repair in the free flap era.

BACKGROUND: Supraclavicular flap (SCF) repair is widely reported in head and neck surgery in select patients and defects. The authors' objective is to present our series of 30 patients who underwent SCF repair for varying defects and to review the scope and outcome of SCF repair in the literature. METHODS: The authors contributed primary evidence of 30 cases of SCF repair. Our outcomes are compared with those reported in the last 5 years' literature; 33 articles published between January 2012 and January 2017 that present original clinical experience of 528 SCFs. RESULTS: SCF is suitable for a wide variety of oral cavity, pharyngeal, skull base and cutaneous defects. Consistent with our experience, SCF is highly reliable even in previously irradiated or dissected necks, so long as the supraclavicular artery is intact. Our case series shows minor complications in 3/30 (10%) and flap loss in 1/30 (3.3%) cases. The literature reports a similar rate of complete flap failure of 3.4% and a slightly higher average minor complication rate of 24.6%. CONCLUSION: We add our experience of 30 cases of SCF repair to the international literature. We experienced a complication rate lower than the reported average, and maintain that the SCF is an excellent reconstructive option in patients with previously irradiated necks or comorbidities that affect microvasculature and anaesthetic resilience.