Surgical treatment of Boerhaave syndrome in the past, present and future: updated results of a specialised surgical unit.

INTRODUCTION: Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis. METHODS: This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade. RESULTS: Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011. CONCLUSIONS: Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.

A Modified AUGIS Delphi Process to Establish Future Research Priorities in Benign Upper Gastrointestinal Surgery.

BACKGROUND: The aim of our study was to use a modified Delphi process to determine the research priorities amongst benign upper gastrointestinal (UGI) surgeons in the United Kingdom. METHODS: Delphi methodology may be utilised to develop consensus opinion amongst a group of experts. Members of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland were invited to submit individual research questions via an online survey (phase I). Two rounds of prioritisation by multidisciplinary expert healthcare professionals (phase II and III) were completed to determine a final list of high-priority research questions. RESULTS: Four hundred and twenty-seven questions were submitted in phase I, and 51 with a benign UGI focus were taken forward for prioritisation in phase II. Twenty-eight questions were ranked in phase III. A final list of 11 high-priority questions had an emphasis on acute pancreatitis, Barrett's oesophagus and benign biliary disease. CONCLUSION: A modified Delphi process has produced a list of 11 high-priority research questions in benign UGI surgery. Future studies and awards from funding bodies should reflect this consensus list of prioritised questions in the interest of improving patient care and encouraging collaborative research.

Effects of physical randomness training on virtual and laboratory golf putting performance in novices.

External randomness exists in all sports but is perhaps most obvious in golf putting where robotic putters sink only 80% of 5 m putts due to unpredictable ball-green dynamics. The purpose of this study was to test whether physical randomness training can improve putting performance in novices. A virtual random-physics golf-putting game was developed based on controlled ball-roll data. Thirty-two subjects were assigned a unique randomness gain (RG) ranging from 0.1 to 2.0-times real-world randomness. Putter face kinematics were measured in 5 m laboratory putts before and after five days of virtual training. Performance was quantified using putt success rate and "miss-adjustment correlation" (MAC), the correlation between left-right miss magnitude and subsequent right-left kinematic adjustments. Results showed no RG-success correlation (r = -0.066, p = 0.719) but mildly stronger correlations with MAC for face angle (r = -0.168, p = 0.358) and clubhead path (r = -0.302, p = 0.093). The strongest RG-MAC correlation was observed during virtual training (r = -0.692, p < 0.001). These results suggest that subjects quickly adapt to physical randomness in virtual training, and also that this learning may weakly transfer to real golf putting kinematics. Adaptation to external physical randomness during virtual training may therefore help golfers adapt to external randomness in real-world environments.

The prevalence of NAFLD and NASH among patients with psoriasis in a tertiary care dermatology and rheumatology clinic.

BACKGROUND: Psoriasis has been linked to metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Data suggest that the prevalence of NAFLD is increased in patients with psoriasis. The aim of this study was to determine the prevalence and severity of NAFLD in this patient population. AIM: To determine the prevalence of both NAFLD and non-alcoholic steatohepatitis (NASH) in patients with psoriasis. METHODS: Patients between the ages of 18 and 70 years with a diagnosis of psoriasis or psoriatic arthritis and followed by either the Dermatology or Rheumatology Division within the Department of Medicine at San Antonio Military Medical Center were considered for enrollment. Each patient completed a questionnaire, underwent a thorough skin evaluation, and had a right upper quadrant ultrasound and fasting blood work. If the liver enzymes were elevated or fatty liver detected on imaging, percutaneous liver biopsy was recommended. RESULTS: One hundred and twenty-nine patients were enrolled and 103 completed all necessary studies. The participants were predominantly middle aged (52.7 ± 12) and overweight or obese (average BMI 30.1 ± 5.9, range: 19.8-52.5 kg/m(2)). 53% (n = 54) were male while 15% (n = 15) of participants identified themselves as being a diabetic. The overall prevalence of NAFLD was 47%. The overall prevalence of NASH was 22% in those who underwent biopsy. CONCLUSIONS: Non-alcoholic fatty liver disease is very common among our cohort of patients with psoriasis, occurring in roughly 47% of patients. The more progressive form of the disease, NASH, is found in approximately one in five patients. Health care providers should be mindful of this association given the high prevalence of both NAFLD and NASH in this cohort of patients.

Outcomes following Boerhaave's syndrome.

INTRODUCTION: Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit. METHODS: Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay. RESULTS: Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days. CONCLUSIONS: Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Boerhaave's syndrome secondary to gastric volvulus.

Boerhaave's syndrome is oesophageal rupture as a result of forceful vomiting or retching against a closed cricopharyngeus. We report the case of an 81-year-old man with oesophageal rupture secondary to volvulus of an intrathoracic stomach who underwent laparotomy with a repair of the oesophageal perforation and intrathoracic stomach, making a good recovery. This case demonstrates another life-threatening complication of an intrathoracic stomach and highlights the importance of an early diagnosis and the advantages of using a transabdominal approach in this situation.

Long-term outcomes of revisional surgery following laparoscopic fundoplication.

BACKGROUND: A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long-term clinical outcomes. METHODS: Patients requiring late revisional surgery following laparoscopic fundoplication for gastro-oesophageal reflux were identified from a prospective database. Long-term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction. RESULTS: The database search found 109 patients, including 98 (5.6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow-up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62.7 per cent) or satisfied (23.5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0.004), troublesome dysphagia (16 versus 6 per cent; P = 0.118) and a lower satisfaction score (P = 0.023) than those with recurrent reflux or paraoesophageal herniation. CONCLUSION: Revisional surgery following laparoscopic fundoplication can produce good long-term results, but revision for dysphagia has less satisfactory outcomes.

Spontaneous rupture of the oesophagus.

BACKGROUND: The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre. METHODS: Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy. RESULTS: The median time to diagnosis was 24 (range 4-604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Ttube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention. CONCLUSION: Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.

Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma.

BACKGROUND: About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy. METHODS: Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. (99m)Tc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment. RESULTS: A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9.6 per cent). CONCLUSION: Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

Assessment of the need to coat particle collection cups of the NGI to mitigate droplet bounce when evaluating nebuliser-produced droplets.

The European Pharmaceutical Aerosol Group (EPAG) has been undertaking a series of investigations in support of developing robust methods for the droplet size analysis of nebuliser-produced aerosols for the proposed European Pharmacopoeia general chapter 2.9.44 covering preparations for nebulisation. The present two-centre study, which was designed to confirm whether or not coating the collection cups of the Next Generation pharmaceutical Impactor (NGI, the recommended impactor for the proposed monograph) is required, forms part of these investigations. The study evaluated NGI-measured aerodynamic droplet-size distributions of aerosols of a generic salbutamol solution for nebulisation generated by two different jet nebulisers. The results demonstrated that there was no indication of biased stage deposition when silicone oil was used to coat the impaction surfaces, as compared to uncoated surfaces. The conclusion was that there is no need to coat the NGI cups when nebulised products are investigated.

Cooling the NGI - an approach to size a nebulised aerosol more accurately.

The European Pharmaceutical Aerosol Group (EPAG) has undertaken investigations with the aim of developing robust methods for the droplet size analysis of nebuliser-produced aerosols in support of the proposed European Pharmacopeia general chapter 2.9.44 covering preparations for nebulisation. A multi-centre study was designed to investigate the effects of cooling the Next Generation pharmaceutical Impactor (NGI) before sample collection, as a means of reducing bias and variability caused by heat transfer-related evaporation. Droplets containing salbutamol were sized from 3 different nebulisers chosen to offer fundamentally different modes of aerosol generation: AeroNeb Go, a vibrating mesh nebuliser; PARI LC Plus, a breath-enhanced jet nebuliser; and MistyMax, a constant-output jet nebuliser. Each laboratory undertook determinations at ambient temperature, using an NGI pre-cooled in a refrigerator (5 degrees C for at least 90 min). The corresponding measurements were made using an ambient NGI as a benchmark. Salbutamol solution 5 mg/2 ml (Teva, Runcorn, UK) was used throughout the study. Analysis of individual and pooled results from 5 of the participants showed a similar trend insofar as the cooled NGI yielded a coarser nebulised aerosol than that obtained by the ambient NGI. Mass Median Aerodynamic Diameter (MMAD) was on average reduced by 9.5-21.9 % and the Fine Droplet Fraction < 5 microm (FDF) increased on average by 5.5-17.4 % for all the nebuliser designs when comparing ambient to cooled NGI. Despite the more laborious procedure of cooling the NGI, variability in data was generally similar to that obtained with the ambient NGI. We conclude that it is beneficial to cool the NGI when sizing nebulised aerosol. Furthermore, occasional findings during this study revealed a build-up of solute deposits within the interior of the NGI, and a more rigorous impactor cleaning/drying procedure is therefore recommended.

Position paper: recommendation on the adoption of breathing patterns for infants and small children in general chapter 2.9.44. Preparations for nebulisation.

The treatment of infants and small children with nebuliser-based therapy is commonplace. However, the breathing pattern proposed for general chapter 2.9.44 covering preparations for nebulisation, in development for the European Pharmacopoeia, is that of an adult at rest. This position paper is a concise summary of recommendations for 3 breathing patterns that would be applicable to a neonate, a 12-month-old infant, and a child approximately 4 years old. The information presented herein is intended to inform the development of the proposed general chapter with the intention that information be provided to assist those involved with the evaluation of preparations for paediatric use in the choice of more appropriate breathing patterns for the assessment of active substance delivery rate and total active substance delivered.

The novel tyrosine kinase inhibitor EXEL-0862 induces apoptosis in human FIP1L1-PDGFR-alpha-expressing cells through caspase-3-mediated cleavage of Mcl-1.

The FIP1-like-1 (FIP1L1)-platelet-derived growth factor receptor-alpha (FIP1L1-PDGFR-alpha) fusion kinase causes hypereosinophilic syndrome (HES) in a defined subset of patients. Imatinib mesylate is a potent inhibitor of ABL but also of PDGFR-alpha, and has been associated with durable hematologic responses in patients with HES. However, development of mutations in the tyrosine kinase domain may hamper the activity of tyrosine kinase inhibitors (TKIs), which suggests that novel agents are warranted to prevent or overcome resistance. We evaluated the efficacy of the novel TKI EXEL-0862 in FIP1L1-PDGFR-alpha-expressing cell lines and in cells from a patient with HES harboring the FIP1L1-PDGFR-alpha gene. EXEL-0862 inhibited the proliferation of EOL-1 and imatinib-resistant T674I FIP1L1-PDGFR-alpha-expressing cells and resulted in potent inhibition of the phosphorylation of PDGFR-alpha and downstream proteins STAT3 and Erk1/2, both in vitro and ex vivo. Moreover, EXEL-0862 induced apoptotic death in EOL-1 cells and imatinib-resistant T674I FIP1L1-PDGFR-alpha-expressing cells, and resulted in significant downregulation of the antiapoptotic protein Mcl-1 through a caspase-dependent mechanism. Our data establish EXEL-0862 as a solid candidate for the targeted treatment of patients with FIP1L1-PDGFR-alpha-positive HES.

An outbreak of E. coli O157 associated with a swimming pool: an unusual vehicle of transmission.

Escherichia coli O157 causes a range of illnesses from mild diarrhoea to haemolytic uraemic syndrome (HUS) which carries a mortality rate of 3.7%. Infection is more common in the under-5s. Between 1995 and 2000, 106 outbreaks of E. coli O157 were reported in England and Wales. Recreational water is well documented as a transmission route for infectious diseases worldwide. In the United Kingdom there have been very few reported outbreaks associated with swimming pools due to the relative susceptibility of E. coli O157 to adequate levels of free chlorine. This report describes the investigation of an outbreak associated with a local leisure centre pool and makes recommendations about the safe management of such facilities.

Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma.

BACKGROUND: The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma. METHODS: Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of (99m)Tc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld gamma probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases. RESULTS: SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P < 0.001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P < 0.001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0.018), radioactive uptake (P < 0.001) and malignant nodes (P = 0.004) in the mediastinum than gastric cardia tumours. CONCLUSION: The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Prospective study of routine contrast radiology after total gastrectomy.

BACKGROUND: The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation. METHODS: Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy. RESULTS: Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak. CONCLUSION: There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Comparison of three different procedures for antireflux surgery.

BACKGROUND: No long-term comparisons of the various open and laparoscopic antireflux procedures have been undertaken. The aim of this study was to compare symptomatic outcomes of three procedures for antireflux surgery performed at three specialist units. METHODS: Patients undergoing open Nissen fundoplication, laparoscopic Nissen fundoplication and laparoscopic anterior partial fundoplication between December 1993 and February 2001 were identified. Patient outcome was assessed by means of a postal questionnaire. This was a hypothesis-generating study. RESULTS: Three hundred and fifty-seven patients (80.0 per cent) completed the questionnaire, with no differences in response rate between centres. Overall, a mean of only 7.6 per cent of patients reported a poor outcome. Logistic regression revealed no significant differences amongst the three procedures for any symptoms, after allowing for the effect of time. There was a general increase in the DeMeester score with increasing time from operation. The incidence of revisional reflux surgery was similar in the three groups. CONCLUSION: Medium-term symptomatic outcome following all three procedures was similar. There was some recurrence of symptoms of gastro-oesophageal reflux with time for all procedures, suggesting that the effects of surgery diminish with time. The level of experience of the surgeon in a particular operation was more important than the procedure performed.

[Prognosis of severe trauma outcome using noninvasive monitoring]. / Predskazanie iskhoda tiazheloi travmy s pomoshch'iu neinvazivnogo monitoringa.

The purpose of the case study was, firstly, to evaluate (starting from the time the patients are admitted to the intensive care unit--ICU) a type of cardiac, pulmonary and peripheral microcirculation in patients with severe traumas by using a multi-component and invasion-free monitoring; the second purpose was to measure quantitatively the changes in the cardiac, pulmonary and peripheral hemodynamics leading to recovery or death; and finally, it was to investigate the effectiveness of applying the discriminative analysis for the sake of assessing the biological value of the controllable changes and of forecast outcome. The invasion-free monitoring system comprising the below tools was in use: an improved bio-impedance method (evaluation of the cardiac output), pulsometry (examination of the pulmonary function), transcutaneous oxygen pressure (tissue perfusion function) and arterial blood pressure (ABP--general circulation status). The results of continuously controllable invasion-free measurements were used for a prospective evaluation at the emergency unit of the county hospital, which was supervised by the university. The accumulated integral values of the deficit or excess of each controllable parameter were calculated by using the differences between the normal values and the values obtained for each patient and for the groups of survivors and dead. A probable outcome and a degree of the deficit of the pulmonary and cardiac functions as well as of the tissue-perfusion function were analyzed by using the discriminant function. The values of pure aggregate deficits (-) or excesses (+) were for the survivors and dead, respectively, as follows: cardiac index--(+)93 +/- 49.8 l/m2 versus -232 +/- 138 l/m2 (p < 0.07); mean ABD(-)-12 +/- 12.4 mm Hg versus -57 +/- 23.5 mm Hg (p < 0.066); arterial saturation(-)-1 +/- 0.09% h versus -9 +/- 2.6% h (p < 0.001): and tissue perfusion--(+)311 +/- 87 tor/h versus 793 +/- 175 tor/h (p < 0.0001). The pure aggregate value of reduced circulation, tissue perfusion and of hypoxemia degree was found to be higher in the dead versus the survivors. The invasion-free monitoring systems secure a constant real-time control over the data, which makes the circulatory malfunction revealed as soon as possible in emergency settings. The mentioned systems can be used to describe, for each patients, a temporal hemodynamic model and to evaluate quantitatively a functional-deficit severity; they also provide for composing a clear-cut and successive treatment scheme from the emergency stage to the intensive care unit.