Variation in outcomes and use of laparoscopy in elective inguinal hernia repair.

Background: The early outcomes of inguinal hernia repair in routine practice and the extent to which the laparoscopic approach is used are unknown. The aims of this study were to identify national benchmarks for early reoperation and readmission rates, to identify the degree to which the laparoscopic approach is used for elective hernia surgery in England, and to identify whether there is any variation nationally. Methods: All adults who underwent publically funded elective inguinal hernia repair in England during the six financial years from 2011-2012 to 2016-2017 were identified in the Surgeon's Workload Outcomes and Research Database (SWORD). Patients were grouped according to whether they had a primary, recurrent or bilateral hernia, and according to sex. Overall rates of readmission, reoperation and laparoscopic approach were calculated, and variation was assessed using funnel plots. Results: Some 390 777 patients were included. Overall, 11 448 patients (2·9 per cent) were readmitted to hospital as an emergency within 30 days of surgery and 2872 (0·7 per cent) had a further operation. Laparoscopic repair was performed for 65·5 per cent of bilateral inguinal hernias compared with 17·1 per cent of primary unilateral inguinal hernias, 31·3 per cent of recurrent hernia repairs and 14·0 per cent of primary unilateral hernias in women. The unadjusted readmission, reoperation and laparoscopy rates varied significantly between hospitals. Conclusion: The likelihood of a patient being readmitted to hospital, having an emergency reoperation or undergoing laparoscopic inguinal hernia repair varies significantly depending on the hospital to which they are referred. Hospitals and service commissioners should use this data to drive service improvement and reduce this variation.

Nutrient intake and contribution of home enteral nutrition to meeting nutritional requirements after oesophagectomy and total gastrectomy.

BACKGROUND/OBJECTIVES: This study evaluated nutrition after oesophago-gastric resection and the influence of home jejunostomy feeding in the six months after surgery. SUBJECTS/METHODS: Data on nutritional intake and physiologic measures were collected as part of a randomised trial with measurements taken before and up to six months after surgery. RESULTS: A total of 41 participants (32 oesophagectomy, 9 total gastrectomy) received home jejunostomy feeding (n=18) or usual care without feeding (n=23). At hospital discharge, oral intakes were adequate for energy and protein in 9% and 6%, respectively. By three and six months, these values had increased to 61% and 55%, 94% and 77% respectively. Six participants (26%) who received usual care required rescue feeding. Six weeks after hospital discharge, energy intakes were met in those who received jejunal feeding because of the contribution of enteral nutrition. Jejunal feeding did not affect oral intake, being similar in both groups (fed: 77% estimated need, usual care: 79%). At three months, inadequate micronutrient intakes were seen in over one third. Compared to baseline values, six weeks after surgery, weight loss exceeding 5% was seen in 5/18 (28%) who received feeding, 14/17 (82%) who received usual care and 5/6 (83%) of those who required rescue feeding, P=0.002. Weight loss averaged 4.1% (fed), 10.4% (usual care) and 9.2% (rescue fed), P=0.004. These trends persisted out to six months. CONCLUSIONS: Supplementary jejunostomy feeding made an important contribution to meeting nutrition after oesophago-gastric resection. Importantly, oral nutritional intake was not compromised dispelling the assertion that jejunal feeding deincentivises patients from eating.

Plasma and erythrocyte uptake of omega-3 fatty acids from an intravenous fish oil based lipid emulsion in patients with advanced oesophagogastric cancer.

BACKGROUND: It has been demonstrated that short term intravenous (IV) administration of omega-3 polyunsaturated fatty acids (PUFAs) is more effective than oral supplementation at promoting incorporation of the bioactive omega-3 PUFAs eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) into plasma, blood cells and tissues. The effect of repeated short term IV infusion of omega-3 PUFAs was investigated in patients with advanced oesophagogastric cancer during palliative chemotherapy. METHODS: Patients with advanced oesophagogastric cancer (n = 21) were recruited into a phase II pilot clinical trial. All patients were scheduled for an intravenous infusion of Omegaven® (fish oil supplement containing EPA and DHA) at a rate of 2 ml/kg body weight for 4 h once a week for up to six months. Blood samples were collected to assess omega-3 PUFA uptake into plasma non-esterified fatty acids (NEFAs) and phosphatidylcholine (PC) and into red blood cell (RBC) membranes. Fatty acid profiles were analysed by gas chromatography. RESULTS: Twenty patients received at least one Omegaven® treatment and were included in the analysis. Each infusion of omega-3 PUFAs resulted in increased EPA and DHA in plasma NEFAs, but there was little effect on PUFAs within plasma PC during the infusions. However, with repeated weekly infusion of omega-3 PUFAs, the EPA content of plasma PC and of RBC membranes increased. CONCLUSION: Repeated weekly omega-3 PUFA infusion is effective in enriching plasma PC and RBC membranes in EPA in patients with advanced oesophagogastric cancer receiving palliative chemotherapy. TRIAL REGISTRATION: Clinical Trials.Gov NCT01870791.

Potential applications of fish oils rich in omega-3 polyunsaturated fatty acids in the management of gastrointestinal cancer.

BACKGROUND & AIMS: Despite advances in chemotherapeutic agents and surgical approaches for its management, gastrointestinal cancer still accounts for 27% of new cancer cases and 35% of cancer related mortality worldwide. Omega-3 polyunsaturated fatty acids (PUFAs) specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have anti-inflammatory and anticancer activities and are used as immuno-nutrients. METHODS: A literature search was conducted to identify primary research reporting on applications of the omega-3 PUFAs in gastrointestinal cancer. RESULTS: Reported laboratory studies indicate a clear role for omega-3 PUFAs in preventing cancer development at various stages including cancer cell proliferation, survival, angiogenesis, inflammation and metastasis. In clinical settings, omega-3 PUFAs have been reported to improve the immune response, maintain lean body mass, improve quality of life and improve overall survival in patients with colorectal and pancreatic cancer. In contrast to other GI cancers, there is a strong connection between inflammation and oesophageal cancer. CONCLUSIONS: Little work has been done exploring the role for omega-3 PUFAs in oesophageal cancer prevention and management. The authors are conducting a clinical trial investigating the use of parenteral omega-3 PUFAs supplementary to the standard of care (epirubicin, oxaliplatin and capecitabine palliative chemotherapy) in patients with advanced oesophagogastric cancer as a promising new therapeutic approach.

Taste, smell and appetite change after Roux-en-Y gastric bypass surgery.

BACKGROUND: It is apparent from day-to-day practice that patients frequently report changes to their appetite, taste and smell after weight loss surgery. There has been surprisingly little written in the literature on this. The aim of the current study was to assess these parameters in a cohort of patients undergoing Roux-en-Y gastric bypass surgery. METHODS: Questionnaires relating to appetite, taste and smell were administered to 188 patients who had undergone Roux-en-Y gastric bypass surgery at our institution during the years 2000-2011. RESULTS: Responses were received from 103 patients (55%). Sensory changes in appetite, taste and smell were noted by 97, 73 and 42% of patients, respectively. Seventy-three percent of patients reported aversion to specific foods after surgery, with meat products the most commonly cited (33%). Patients who experienced food aversions experienced more postoperative weight loss and reduction in BMI, compared to their counterparts without these features. CONCLUSIONS: This study indicates that subjective changes in appetite, taste and smell are very common after Roux-en-Y gastric bypass. Patients are now routinely counselled about these changes as part of the informed consent process for surgery.

Venous thromboembolism in patients receiving perioperative chemotherapy for esophagogastric cancer.

The association between venous thromboembolism and chemotherapy for esophagogastric cancer is well known in patients treated with palliative intent. Whether this risk extends to the neoadjuvant and perioperative setting is unclear. A retrospective interrogation of databases of patients receiving perioperative chemotherapy for potentially curative intent at the Leicester (2006-2011) and Nottingham (2004-2011) esophagogastric cancer centers was performed. Thromboembolic events were diagnosed in 48 of 384 patients (12.5%), 21 (5.5%) at presentation, 12 (3%) during neoadjuvant chemotherapy, and 15 (3.9%) in the postoperative period. There were no deaths from thromboembolic disease. By site these comprised catheter-related axillary vein thrombosis in 7 patients, deep venous thrombosis in 12 patients, and pulmonary embolism in 29 patients. Twenty-five of the 29 pulmonary emboli were incidental findings on staging computed tomography imaging. Combination chemotherapy with epirubicin, cisplatin, and capecitabine appeared to carry the greatest risk for the development of thromboembolism. Seven of the 12 patients (58%) who developed thromboembolism during neoadjuvant chemotherapy did not proceed to surgery because of deterioration in performance status. Preoperative thromboembolic disease resulted in a significant increase in the interval between chemotherapy and surgery, but did not influence either length of hospital stay or survival. Venous thromboembolism will develop in 12.5% of patients treated with potentially curative intent. This adverse event can occur at any time during the patient journey. In contrast to the commonly held view, this did not translate into a poorer prognosis.

The "two-week wait" referral pathway allows prompt treatment but does not improve outcome for patients with oesophago-gastric cancer.

INTRODUCTION: The Two Week Wait Referral Service (2WW) has been implemented as a means of fast-tracking patients with suspected upper gastrointestinal cancers for endoscopy. Whether or not it impacts on the outcome of these patients is unclear. The aim of this study was to compare the outcome of patients referred through 2WW with that of patients with oesophago-gastric cancer identified through alternate referral pathways (routine, emergency). METHODS: The study population was 340 patients with oesophago-gastric carcinoma (gastric 154) diagnosed during the time period 01/2006-12/2007 at University Hospitals of Leicester NHS Trust. Data were collected prospectively by the MDT co-ordinator and analysed retrospectively. RESULTS: 135 of the 340 patients with oesophago-gastric cancer were diagnosed through the 2WW, 115 patients through routine referral pathways, and 90 patients were admitted on an emergency basis. Patients referred through 2WW had a median referral to 1st treatment time of 47 days (routine 79, emergency 28, p < 0.001 all group comparisons). The number of patients treated with potentially curative intent was 37 of 135 for the 2WW, 42 of 115 for the routine referrals and 10 of 90 for patients admitted as emergencies. The corresponding median survivals for the groups were 239 days (2WW), 405 days (routine) and 121 days (emergency), p < 0.001 (log rank). CONCLUSIONS: Referral by 2WW resulted in more rapid treatment than routine referral but this did not translate into an improvement in survival. This suggests that the targeting of endoscopy to patients with alarm symptoms is flawed and a less selective approach should be promoted if curable cancers are to be detected.

The early use of PET-CT alters the management of patients with esophageal cancer.

INTRODUCTION: The routine use of positron emission tomography-computed tomography (PET-CT) in the staging of patients with esophageal carcinoma remains contentious, with conflicting reports of its benefit. In our unit, PET-CT has been used routinely in the staging of all patients considered for radical therapy (surgery or chemoradiotherapy). Our aim was to determine the frequency with which PET-CT influenced decision making in the management of patients with carcinoma of the esophagus or gastroesophageal junction. METHODS: CT, PET-CT, and outcome information were collected on 38 patients considered for radical therapy. Patient proformas, with and without PET-CT findings, were constructed and each independently reviewed in a randomized and blinded fashion by five multidisciplinary team members (three surgeons, two oncologists) and a treatment strategy determined. RESULTS: PET-CT changed the staging for ten patients (26%). This translated into a change in management decision for seven patients (18%). The concordance between individual management plans and treatment intent was 79% for CT (150 of 190 decisions) and it was 92% for PET-CT (175 of 190 decisions). Full concordance between multidisciplinary team members was 66% with CT staging and 74% with the addition of PET-CT. CONCLUSION: The use of PET-CT early in the staging algorithm for esophageal carcinoma altered the staging for a quarter of patients and the management for a fifth of patients, supporting its inclusion early in the staging algorithm.

A case of gastric carcinoma and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).

We report a patient in whom the diagnoses of the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and gastric carcinoma were made concurrently. After a gastrectomy, there was resolution of the electrolyte disturbances. This represents the third reported case of this association in the English language literature.

Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked.

BACKGROUND: In August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer. METHODS: The study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival. RESULTS: Gastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had "alarm" symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated "benign" dyspepsia. The patients with "alarm" symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p < 0.001), were less likely to undergo surgical resection (50% vs 95%; p < 0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms. CONCLUSIONS: The use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.

Defining the position of deep inguinal ring in patients with indirect inguinal hernias.

A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.

A study to determine plasma antioxidant concentrations in patients with Barrett's oesophagus.

BACKGROUND: Dietary questionnaire studies have suggested that patients with oesophageal adenocarcinoma are deficient in antioxidants. It is not known whether the same holds true for patients with the precursor lesion, Barrett's oesophagus. AIMS: To evaluate the hypothesis that patients with Barrett's oesophagus are deficient in antioxidants compared with patients without evidence of Barrett's oesophagus. PATIENTS AND METHODS: Plasma antioxidant profiles (copper, selenium, zinc; vitamins A, C, and E; carotenoids) were determined for patients with Barrett's oesophagus (n = 36), patients with erosive oesophagitis (n = 32), and patient controls (n = 35). RESULTS: Patients with Barrett's oesophagus had significantly lower plasma concentrations of selenium, vitamin C, beta cryptoxanthine, and xanthophyll compared with the other groups. CONCLUSIONS: This study confirms the hypothesis that patients with Barrett's oesophagus are deficient in certain antioxidants.

The role of staging investigations for oesophago-gastric carcinoma.

AIMS: To study the frequency with which unresectable disease was identified on pre-operative staging investigations in patients with oesophago-gastric carcinoma, and to audit whether a staging protocol had reduced the rate of exploratory surgery. METHODS: Ninety-eight patients with oesophageal carcinoma, 89 patients with adenocarcinoma of the gastro-oesophageal junction (GOJ) and 68 patients with gastric carcinoma were staged according to a protocol of computerised tomography, laparoscopy and endoscopic ultrasound. RESULTS: The frequency with which each investigation identified unresectable disease was as follows: (a) computerised tomography-oesophagus 12/67, GOJ 13/58, stomach 10/60; (b) laparoscopy-oesophagus 3/22, GOJ 5/45, stomach 8/23; and (c) endoscopic ultrasound-oesophagus 15/55, GOJ 3/30. By tumour location, rates of exploratory surgery were 1/18 for the oesophagus, 12/35 for the GOJ and 4/42 for the stomach. All of the staging failures in patients with GOJ carcinomas related to posterior tumour extension into the lesser sac. CONCLUSIONS: Staging investigations precluded resection in one-third of patients, the greatest yield being for laparoscopy in gastric carcinoma. In spite of this, 18% of patients undergoing surgical intervention underwent exploratory surgery alone, notably patients with GOJ carcinoma.

Histological changes in the oesophageal squamous mucosa: correlation with ambulatory 24 hour pH monitoring.

AIMS: To determine the value of squamous mucosal histology in the assessment of patients with gastro-oesophageal reflux symptoms. METHODS: Sixty six patients with reflux symptoms underwent endoscopy with oesophageal biopsy, manometry, and 24 hour oesophageal pH testing. The following histological features were assessed in squamous mucosa: the degree of basal cell hyperplasia, the degree of papillary zone elongation, and the density of neutrophil and eosinophil infiltration. Comparisons were made between the histological findings and the oesophageal function tests. RESULTS: The correlation between the traditionally accepted histological markers of gastro-oesophageal reflux disease in squamous mucosa and 24 hour pH testing was predominantly negative, with the exception of neutrophil inflammation in the squamous mucosa of patients with complicated reflux disease. CONCLUSIONS: This study was unable to confirm the value of the Ismail-Beigi criteria as histological markers of acid reflux. By inference, biopsy of the oesophageal squamous mucosa is of limited value in the assessment of patients with reflux symptoms.

Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication.

BACKGROUND: Although there have been case reports describing trocar site herniation after laparoscopic fundoplication, its overall prevalence and the risk factors for its development are unclear. METHODS: The records of 320 patients undergoing primary laparoscopic fundoplication as treatment for gastroesophageal reflex disease (GERD) or hiatal hernia between 1991 and 1999 were reviewed retrospectively. Placement of the initial supraumbilical trocar was by the open Hassan technique in all patients. RESULTS: Nine patients (five male) with a mean age 54 years (range, 37-75) developed trocar site herniation, for an overall prevalence of 3%. The mean interval between surgery and diagnosis was 12 months (range, 4-21). In all patients, the hernia occurred at the supraumbilical camera port site. Patients with trocar hernias tended to have a higher body mass index (BMI) than those without hernias (mean BMI, 29.4 kg/m2 vs 27.2 kg/m2, p = 0.13). None of the patients developed intestinal obstruction as a consequence of herniation. To date, all but one of the hernias have been repaired. Six of them required the insertion of a prosthetic mesh. CONCLUSIONS: The prevalence of trocar site herniation after laparoscopic fundoplication was minimal at 3%. All hernias occurred at the midline supraumbilical port, the only site where open trocar insertion was employed. As a consequence of these observations, we have developed a new method of open trocar placement. This method utilizes a paramedian skin incision and separate fascial incisions through anterior and posterior rectus sheathes, with retraction of the rectus abdominis muscle laterally.

Laparoscopic esophageal surgery.

In its 9-year history, laparoscopic esophageal surgery has become second only to gallbladder surgery in the frequency of minimally invasive procedures performed in routine surgical practice. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux. Laparoscopic myotomy has emerged as the optimal form of therapy for achalasia, and staging laparoscopy has been identified as an important adjunct to the preoperative evaluation of esophageal and gastroesophageal junction carcinoma. Laparoscopic paraesophageal hernia repair and remedial laparoscopic antireflux surgery currently are gaining acceptance. Laparoscopic gastroplasty, esophagectomy, and diverticulectomy are undergoing clinical trials, and their roles remain to be defined.