Clinical utility of plain-film abdominal radiographs for inpatients outside standard working hours in a large university teaching hospital.

INTRODUCTION: Plain film abdominal radiographs (PFAs) are frequently the initial investigation ordered for patients with abdominal symptoms. However, increasing use of emergency ultrasound and availability of emergency CT raises the question of whether PFA remains an appropriate first line investigation. We investigated the impact of out of hours (OOH) PFAs on inpatient management. METHODS: All consecutive PFAs over an 8-week period were included to determine the impact on patient management. OOH was classified as from 5pm to 9am Monday to Friday, weekends and bank-holidays. PACS and hospital records were accessed to determine patient pathways. The institution is a tertiary referral centre with 850 acute beds and serves a population of 950,000. RESULTS: A total of 758 consecutive PFAs were performed in total (58.3% male, mean age 58.1 (range 0-93)). 310 (40.9%) were requested from the emergency department (ED) and 382 (50.4%) were requested from wards. 160 (21.1%) met the criteria of OOH, of these 120 (72.2%) were from ED and 28 were on adult inpatients. Of these 28, none had a change in management based on the PFA result. CONCLUSION: Our study suggests that OOH PFAs of inpatients are of limited clinical utility. These patients are exposed to extra radiation. IMPLICATIONS FOR PRACTICE: We propose that OOH PFAs of inpatients should be questioned as a viable investigation due to the limited contribution they offer in managing patients, the deleterious effects they confer on the patient and the associated economic cost. Further studies are needed to assess if these results are generalizable to other large hospitals.

The role of laparoscopic sleeve gastrectomy as a treatment for morbid obesity; review of outcomes.

BACKGROUND: Global prevalence of obesity has soared. Where lifestyle and medical treatments have failed, laparoscopic sleeve gastrectomy (LSG) is increasingly regarded as a good surgical procedure for morbid obesity. Following the introduction of LSG, we assessed our surgical outcomes. METHODS: We reviewed a consecutive series of LSGs from January 2009 to January 2015. Our primary focus was to assess the success of this procedure on the percentage excess body weight loss (%EWL), Body Mass Index (BMI), hypertension and diabetes. Additionally, we evaluated the rate of procedure-related complications. RESULTS: There were 183 consecutive patients evaluated. Median age was 45 years (24-73). The majority were female (73.2 %, n = 134). At 1 year post-op, median %EWL was 57.6 %. There was an associated median reduction in BMI of 16 kg/m2 (0-33). At 2 years, median %EWL was sustained at 58.4 %. The median reduction in BMI was 16 kg/m2 (4-32). At 2-year post-op, 78.9 % of diabetic patients had their diabetic medications completely discontinued, while a further 15.8 % having their medication reduced. 34.6 % of hypertensive patients had their antihypertensives discontinued, with 50 % having medications reduced. There was no procedure related mortality. 3.3 % (n = 6) of patients had a confirmed staple-line leak. CONCLUSION: This study shows LSG is a safe and successful management strategy for morbid obesity. In addition to the direct effects of sustained weight loss, it highlights indirect effects that LSG has on obesity-related health issues, with substantial reduction in diabetic and anti-hypertensive medications. Our results reaffirm international studies of the beneficial effects of LSG on Type II diabetes and hypertension.

Analysis of subsequent publication and impact of abstracts presented at the Sir Peter Freyer Surgical Symposium: Focus on the Plenary Session.

BACKGROUND: The quality of abstracts presented at a conference reflects the academic activity and research productivity of the surgical/scientific association concerned. The abstract to publication rate (44.5 % internationally), is an important indicator of the quality of presented research. AIM: To evaluate the publication rate and impact of abstracts presented at the plenary session of the Sir Peter Freyer Surgical Symposium over a 25-year period (1989-2014), and identify factors influencing publication. METHODS: Plenary abstracts were identified from abstract books of the Symposium from 1989-2014. The authors, institution, subspecialty and research subject were recorded. A Medline search with name of the first and last author, key words and content of all abstracts was conducted to identify related publications. The impact factor (IF) of the journal and the time to publication was recorded. RESULTS: 298 presented abstracts resulted in 168 publications (publication rate: 56 %). Basic Science research accounted for 80 % (n = 237) of the total number of presentations with the remaining 20 % (n = 61) being categorised as clinical research. Overall, cancer research accounted for 48 % of presented work. The average time to publication was 2 ± 7 years, while 11 % of all published studies achieved publication in the year of the symposium. The median impact factor for published research was 3.558 (IF range 0-39). CONCLUSION: These results indicate that the quality of papers presented at the Sir Peter Freyer Surgical Symposium compares favourably with international equivalents, making this meeting an important forum for Irish Academic Surgery.

MicroRNA-21 and PDCD4 expression in colorectal cancer.

INTRODUCTION: MiRNAs regulate gene expression by binding to target sites and initiating translational repression and/or mRNA degradation. Studies have shown that miR-21 exerts its oncogenic activity by targeting the PDCD4 tumour suppressor 3'-UTR. However, the mechanism of this regulation is poorly understood. In colorectal cancer, loss of PDCD4 has been reported in association with increased tumour aggressiveness and poor prognosis. The purpose of this study was to delineate the interaction between PDCD4 and its oncogenic modulator miR-21 in colorectal cancer. METHODS: A cohort of 48 colorectal tumours, 61 normal tissues and 7 polyps were profiled for miR-21 and PDCD4 gene expression. A subset of 48 specimens (31 tumours and 17 normal tissues) were analysed for PDCD4 protein expression by immunohistochemistry. RESULTS: A significant inverse relationship between miR-21 and PDCD4 gene expression (p < 0.001) was identified by RT-qPCR. In addition, significant reduction of PDCD4 (p < 0.001) expression and reciprocal upregulation of miR-21 (p = 0.005) in a progressive manner from tumour-polyp-normal mucosae was identified. Analysis of protein expression by IHC revealed loss of PDCD4 staining in tumour tissue. Patients with disease recurrence had higher levels of miR-21. CONCLUSION: This study demonstrates the inverse relationship between miR-21 and PDCD4, thus suggesting that miR-21 post-transcriptionally modulates PDCD4 via mRNA degradation. Pharmacological manipulation of the miR-21/PDCD4 axis could represent a novel therapeutic strategy in the treatment of colorectal cancer.

Differential miRNA expression in omental adipose tissue and in the circulation of obese patients identifies novel metabolic biomarkers.

BACKGROUND: Omental fat accumulation is associated with development of the metabolic syndrome, although its molecular characteristics are poorly understood. Mi(cro)RNAs (miRNAs), a class of small noncoding RNAs, are known to regulate various metabolic processes, although their role in obesity and the metabolic syndrome is not clearly defined. This study sought to characterize the miRNA expression in omentum, sc fat and in the circulation of obese and nonobese individuals. Their potential as noninvasive metabolic biomarkers was also explored. METHODS: miRNA was extracted from paired omentum and sc fat tissues, and blood samples, from a total of 50 obese and nonobese patients. A miRNA microarray was performed and a panel of differentially expressed miRNAs validated using RQ-PCR. RESULTS: The miRNA expression profiles were unique for omentum and paired sc fat; no correlation in miRNA expression was observed between these two fat depots. Expression of two miRNAs (miR-17-5p and miR-132) differed significantly between obese and nonobese omental fat (P = 0.048 and P = 0.016). This expression pattern was reflected in the circulation in which these same two miRNAs were also significantly dysregulated in blood from obese subjects. The miRNA expression in omental fat and blood from obese patients correlated significantly with body mass index, fasting blood glucose, and glycosylated hemoglobin. CONCLUSION: This study demonstrates that candidate metabolic miRNAs are altered in adipose tissue and circulation of the obese. Omental fat tissue and systemic miRNA levels reflect components of the metabolic syndrome, highlighting their potential as novel biomarkers for this complex syndrome.

Surgery for oesophageal cancer at Galway University Hospital 1993-2008.

BACKGROUND: Surgical volume and outcome remain controversial in the management of oesophageal cancer. AIMS: To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH). METHODS: Between 1994 and 2008, patients who underwent oesophagectomy were analysed. RESULTS: During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively. CONCLUSIONS: Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.

Sustained weight loss and improvement of quality of life after laparoscopic adjustable gastric banding for morbid obesity: a single surgeon experience in Ireland.

BACKGROUND: Although substantial weight loss is the primary outcome following bariatric surgery, changes in obesity-related morbidity and quality of life (QoL) are equally important. This study reports on weight loss, QoL and health outcomes following laparoscopic adjustable gastric banding (LAGB). METHODS: Bariatric analysis and reporting outcome system questionnaire survey was carried out on patients who had LAGB. Patients' body weight, body mass index, QoL and co-morbidities were recorded. RESULTS: Twenty-three of 26 patients answered the questionnaire (response rate of 92%). Fifteen patients (60%) achieved over 50% excess weight loss. Twenty-two patients (84.6%) reported improvement in QoL. Co-morbidities in 18 patients (75%) resolved or improved. One patient had postoperative aspiration pneumonia and no other morbidity was recorded. CONCLUSIONS: Laparoscopic adjustable gastric banding is a safe and feasible method of bariatric surgery. It can achieve satisfactory weight loss with significant improvement in QoL and co-morbidity provided patients undergo thorough preoperative preparation and rigorous postoperative follow-up.

A novel technique for repair of iatrogenic tracheal tear complicating three-stage oesophagectomy.

We report a rare case of iatrogenic tracheal tear during a three-stage oesophagectomy in a 76-year-old woman and review current literature. The tear occurred due to trauma from a double lumen endotracheal tube. We used a novel technique of repairing the tear, which extended to the carina, avoiding a second thoracotomy or full sternotomy by using the laparoscopic suturing instruments.

Linear stapling of the short gastric vessels reduces blood loss and splenectomy at oesophageal and gastric surgery.

BACKGROUND: Increased operative blood loss, blood transfusion and nontherapeutic splenectomy negatively influence postoperative morbidity and mortality following esophageal or gastric resection. A critical point at which blood loss and iatrogenic splenic injury occurs is at the time of division of the short gastric vessels. We examined the efficacy of using a laparoscopic linear cutting stapler (developed for minimal access surgery) to divide with the short gastric vessels at open surgery. METHODS: Fifty-six patients were included. In 28 consecutive patients the linear stapler was used when dividing the short gastric vessels. These were compared to 28 matched controls (short gastric vessels were divided between hemostats and ligated). In the two patient groups, patient age, body mass index, and preoperative hemoglobin levels were similar. RESULTS: Operation time, splenectomy rates, blood transfusion, and mean transfusion volume were all significantly reduced in the group where the stapler was used. CONCLUSION: Use of a linear cutting stapler reduced operation time, blood product use, and incidental splenectomy in patients undergoing radical open esophageal and gastric surgery.

CDH1 associated gastric cancer: a report of a family and review of the literature.

AIMS: Hereditary diffuse gastric cancer (HDGC) is an autosomal-dominant inherited form of gastric cancer associated with inactivating germline mutations in the CDH1 gene. We set out to outline the role of CDH1 in HDGC. Investigation of a family suspected as having HDGC is discussed. The role of surgery in the management of affected individuals is then examined. METHODS: A search was conducted of Medline and the National Library of Medicine to identify key articles concerning CDH1 gene mutations, familial gastric cancer and gastrectomy. Further, relevant articles were obtained by manual scanning of the reference lists of identified papers. Mutation-specific CDH1 genetic testing was performed on six living family members and on gastric tissue obtained from two deceased members. RESULTS: CDH1 mutations cause inactivation of the cell adhesion protein E-cadherin. Carriers of the CDH1 germline gene mutation develop an aggressive, diffuse, submucosal gastric cancer at an early age. Current endoscopic screening is ineffective at detecting HDGC. The presence of a CDH1 germline gene mutation was confirmed in both deceased family members and also in four of the six living members tested. CONCLUSION: Genetic counselling and CDH1 gene mutation testing is indicated in families with suspected HDGC. In the absence of a satisfactory surveillance mechanism, prophylactic total gastrectomy would appear to be an appropriate therapeutic option in mutation carriers.

Experience of surgery for rectal cancer with total mesorectal excision in a general surgical practice.

BACKGROUND: Results from specialist centres have shown that total mesorectal excision (TME) produces excellent control of local disease in patients with carcinoma of the rectum. METHODS: The results of TME were reviewed in a surgical practice in which patients with rectal cancer comprised 1 per cent of the total caseload and mean case numbers were less than 15 each year. RESULTS: Eighty-two consecutive patients underwent rectal excision with TME over a 72-month period (68 anterior resection, eight abdominoperineal excision and six Hartmann's procedure). Sixty-nine operations were deemed 'curative' at the time of surgery. Anastomotic leak occurred in two (3 per cent) of 68 patients, both of whom recovered without additional surgery. There were two local recurrences (3 per cent) among 69 patients who underwent 'curative' surgery. At a median follow-up of 190 weeks, the survival rate for Dukes' stage A, B, C and 'D' was 100, 83, 68 and 18 per cent respectively. CONCLUSION: Outcome as measured by perioperative morbidity and local disease control achieved in a surgical practice with a broad case mix and relatively low annual case volume was comparable to that from larger centres. Appropriate surgical training and attention to technical detail may be as important as case volume in determining outcome after surgery for rectal cancer.

Video-assisted thoracoscopic surgery in the management of loculated empyema.

BACKGROUND: Fibropurulent empyema (stage II of Light) does not respond to antibiotic therapy and simple drainage. If the condition is inadequately treated, restrictive pulmonary deficit develops, necessitating thoracotomy and decortication. We report our experience with the videoscopic management of stage II and limited stage III disease. METHODS: Ten consecutive patients underwent videoscopic debridement of fibropurulent empyema; three of them required removal of limited visceral and parietal rind. RESULTS: The mean operating time was 42 +/- 8.1 min. Postoperative pyrexia and leucocytosis settled within 4.2 +/- 2.1 days and 13.1 +/- 3.2 days, respectively. Intercostal chest tubes were removed by 4.5 +/- 1.0 days. The mean fall in hematocrit following surgery was 4.9%. Parenteral analgesics were required for 1.0 +/- 0.5 days and oral analgesics for 3 +/- 1.6 days. The mean postoperative stay was 11 +/- 8.1 days. No patient required any further intervention. CONCLUSIONS: Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema.