Proximal acid reflux treated by fundoplication predicts a good outcome for chronic cough attributable to gastro-oesophageal reflux disease.

PURPOSE: The aim for this study is to examine whether proximal, as opposed to distal, oesophageal reflux predicts a good outcome after fundoplication in patients with suspected acid-induced chronic cough. METHOD: Between 1999 and 2007, 81 patients with refractory chronic cough underwent manometry and dual-probe pH studies. In 59 patients, pathological reflux was confirmed, and 21 of these underwent laparoscopic fundoplication by a single surgeon. Proximal reflux was defined as an upper channel time pH <4 of >1.4%. The Chi-square test and Mann-Whitney U test were used in the statistical analysis. RESULTS: All patients with heartburn had their symptoms abolished by surgery. The proximal extent of reflux predicted cough improvement. Eleven of 14 patients with proven proximal reflux had complete symptom relief from surgery as opposed to two of seven with distal only reflux (Chi-square = 4.95; degrees of freedom = 1; p = 0.026). There was no correlation between oesophageal motility (as assessed by per cent abnormal wet swallows) and pathological reflux on outcome of surgery. Correlation of episodes of coughing with episodes of proximal or distal reflux was poor and had no useful predictive value. CONCLUSION: Patients with refractory chronic cough are significantly more likely to benefit from surgery if their pH study shows an upper channel pH time >1%.

What happens to esophageal varices after transection and devascularization?

In 14 patients who underwent endoscopic examination after esophageal transection and proximal gastric devascularization, varices disappeared in seven patients, were reduced in diameter or number in six patients, and were unchanged in one patient. No varices were present in any patient within 1 cm of the stapled anastomosis, and Doppler studies showed no flow in residual varices. During a mean follow-up of 20 months (range: 6 to 44 months), varices recurred in three patients and enlarged in five others. This study suggests that variceal obliteration, a reduction in variceal diameter, the removal of the bleeding zone in the esophagus, and undetectable blood flow in residual varices all contribute to the prevention of variceal rebleeding; although these changes are not always permanent, the return to the preoperative state may take many years.

Bleeding anorectal varices--a misunderstood condition.

The management of 13 patients who had bleeding anorectal varices is described and compared with the 20 cases reported to date. The diagnostic procedure of choice is anorectoscopy. Treatment by an under-running suture achieved primary control of bleeding in all patients, and during a median follow-up of 7 months (range, 1 to 36), two early and one late episodes of rebleeding occurred. As all patients had varices in the anal canal with only occasional extension into the rectum, the term "anorectal varices" is to be preferred.

Gastroaortic fistula as an early complication of esophagectomy.

Gastroaortic fistula following esophagogastrectomy is an uncommon and invariably fatal complication without urgent surgical intervention. We report 1 such case and review the world literature identifying 22 previous cases. It characteristically presents 2 to 3 weeks after esophagogastrectomy with an initial herald bleed, followed by a latent period with a mean duration of 10 hours (range: 30 minutes to 3 days) and final exsanguination. Only 1 patient in this series survived. Awareness is necessary to allow prompt diagnosis and treatment of this almost invariably lethal but curable condition.

Club foot. Observations on the surgical anatomy of dorsiflexion.

Dorsiflexion has been studied in three normal feet and in three feet with talipes equinovarus to determine the anatomical features which might contribute to the failure of operative treatment to correct the deformity. In the normal feet the movement of dorsiflexion was found to be essentially rotatory in nature and not simply hinging; as dorsiflexion proceeds the fibula moves forwards relative to the os calcis and the calcaneal tendon. In the club feet a posterolateral tether was found; this prevented fibular movement and blocked dorsiflexion. As a result of this study a posterior and lateral release is advocated for the operative correction of the hindfoot in a child with a club foot deformity, particularly under the age of a year.

Testicular torsion: most delay occurs outside hospital.

Testicular torsion leading to orchidectomy is a major catastrophe for the patient and continues to occur. We studied the causes of delay leading to orchidectomy by conducting a retrospective hospital-based audit of all patients undergoing scrotal exploration for suspected testicular torsion over a 2 year period. Fifty patients underwent surgery of whom 22 (44%) had testicular torsion and six required orchidectomy. All patients with a dead testicle presented more than 6 h after onset of symptoms. Of those presenting with 6, 24 or more than 24 h of symptoms, salvageable testes were found in 100%, 83% and 75%, respectively. The median duration of symptoms in patients with viable twisted testicle was 5.5 h compared with 42 h in those who underwent orchidectomy. Late presentation to hospital was the major cause of delay leading to orchidectomy in patients with testicular torsion. Greater effort in health education and direct or self-referral to hospital may reduce this delay.

Safe transition from open to laparoscopic fundoplication by an established consultant--the importance of repeated audit.

BACKGROUND: Serious complications of laparoscopic fundoplication (LF) have been reported by surgeons new to LF. We investigated whether the reported benefits of LF could be realised by an established consultant, new to LF, without compromising safety, control of reflux or dysphagia rates obtained after open surgery. PATIENTS AND METHODS: Outcome of 65 consecutive open fundoplications was audited. After training in LF, this audit was compared with an identical prospective audit of 65 patients undergoing LF. RESULTS: No significant differences occurred between the two groups in relief of reflux. LF resulted in: (i) shorter postoperative stay (median 2 days versus 7 days, P < 0.001); (ii) earlier return to work (median 4 weeks versus 9 weeks, P < 0.001); (iii) shorter duration of postoperative dysphagia (median 4 weeks versus 9 weeks, P = 0.01); and (iv) less intra/postoperative complications (7.7% versus 32.3%, P < 0.001). CONCLUSIONS: LF can be introduced safely by established consultants provided that adequacy of training is confirmed by repeated audit.

Management of bleeding varices in the elderly.

In 207 consecutive patients the outcome of bleeding varices was compared in those aged under 65 (n = 146) and those aged over 65 (n = 61). All patients were seen during seven years and were treated by active initial and maintenance sclerotherapy. Alcoholic cirrhosis was commoner in younger patients (68 (47%) v 12 (20%] and cryptogenic cirrhosis commoner in older patients (21 (34%) v 19 (13%]. Mortality due to the first bleed was dependent on the severity of liver disease and was unrelated to age. Survival corrected for age (life table analysis) was 65% at one year and 60% at two years for both groups of patients. It is concluded that patients should not be denied active treatment for bleeding varices on the basis of age alone. In order to obtain optimum results early endoscopy and sclerotherapy is essential.

Randomised controlled trial of short term treatment to eradicate Helicobacter pylori in patients with duodenal ulcer.

OBJECTIVE: To determine whether one week's drug treatment is sufficient to eradicate Helicobacter pylori in patients with duodenal ulcer. DESIGN: Single blind, randomised controlled trial. SETTING: Specialised ulcer clinic in a teaching hospital. PATIENTS: 155 patients with H pylori and a duodenal ulcer verified endoscopically which had either bled within the previous 24 hours or was causing dyspepsia. INTERVENTIONS: Patients were allocated randomly to receive either omeprazole for four weeks plus bismuth 120 mg, tetracycline 500 mg, and metronidazole 400 mg (all four times a day) for the first week (n = 78), or omeprazole alone for four weeks (n = 77). Further endoscopy was performed four weeks after cessation of all drugs. MAIN OUTCOME MEASURES: Presence or absence of H pylori (by urease testing, microscopy, and culture of antral biopsy specimens), duodenal ulcer, and side effects. RESULTS: Eradication of H pylori occurred in 70 (95%) patients taking the four drugs (95% confidence interval 86% to 97%) compared with three (4%) patients taking omeprazole alone (1% to 11%). Duodenal ulcers were found in four (5%) patients taking the four drugs (2% to 12%) and in 16 (22%) patients taking omeprazole alone (14% to 32%). Mild dizziness was the only reported side effect (six patients in each group) and did not affect compliance. CONCLUSIONS: A one week regimen of bismuth, tetracycline, and metronidazole is safe and effective in eradicating H pylori and reduces the number of duodenal ulcers four weeks after completing treatment.

Spontaneous perforation of a pyometra presenting as generalized peritonitis.

Eleven cases of spontaneous perforation of a pyometra have previously been reported. All were associated with, and probably secondary to, cervical occlusion. A further case is described, but differs in that the cervical canal was patent. In the absence of other possible causes of uterine perforation, the aetiology of the perforation in this case remains uncertain.

A study of anatomy and biomechanics of the ankle region in normal and club feet (talipes equino varus) of infants.

Three normal feet and three feet exhibiting talipes equino varus from infants were dissected and their anatomy studied and compared. The tibiae were immobilised in plaster and held in a bench clamp while the range of dorsiflexion (extension) was studied before and after immobilisation of either the medial or lateral, or of both groups of tendons. Movements at the subtalar and ankle joints were studied as well as factors controlling movements at the subtalar joint. There was minimal subtalar movement in normal feet during dorsiflexion (extention) but for the clubbed feet the joint showed far greater movement. Tethering of the lateral malleolus to the calcaneum by a suture, in normal feet, caused similar biomechanical behaviour to that seen in clubbed feet.

Can follow-up sclerotherapy for oesophageal varices be improved? Early results of a new technique.

To help correctly identify varices as patent or thrombosed during follow-up sclerotherapy, a simple pressure device has been used to obtain intravariceal pressure. A high pressure denotes thrombosis and a low pressure (less than 50 mmHg) denotes patency. In 217 variceal assessments, conventional and pressure assessments agreed in 179 (82%). Over the 7 month study, a significant improvement was noted in correctly diagnosing thrombosed varices (p less than 0.01). No ulcers, bleeding or complications occurred. Pressure assessment of varices is simple and avoided 38 (18%) incorrect diagnoses and their consequences.

Graded exercises for basic training in laparoscopic surgery.

A series of graded exercises for use in laparoscopic simulation is described. These exercises are designed to introduce the basic skills required for laparoscopic surgery, and have been found to be useful both for the training of junior surgeons and in workshops.

Effect of Valsalva's manoeuvre and hyoscinbutylbromide on the pressure gradient across the wall of oesophageal varices.

To assess whether Valsalva's manoeuvre might cause variceal bleeding, 22 patients with oesophageal varices were studied. In 12 patients who received no previous treatment to their varices the median pressure gradient across the varix wall at rest was 19 (6-36) mmHg, and in 10 patients whose varices were thrombosed at their distal end the median pressure gradient in the proximal patent varix was 8 (1-6) mmHg. In untreated patients groups, the pressure gradient rose by 6-12 mmHg during Valsalva's manoeuvre in four patients, fell by 4-11 mmHg in five patients and was virtually unchanged in the remainder. These changes seem unlikely to cause variceal bleeding. Patients who repeated Valsalva's manoeuvre showed similar changes on each occasion. Six patients in the untreated group also received hyoscinbutylbromide 20 mg iv. No change was seen in the pressure gradient in five patients, suggesting that it is of little value in preventing variceal bleeding.

Usefulness of manometric assessment of varices in maintenance sclerotherapy. A controlled trial.

In a prospective controlled study, 68 patients undergoing maintenance sclerotherapy were randomized to have intravariceal sclerotherapy based on either manometric assessment (n = 35) or visual assessment (controls, n = 33) of varix patency. For manometric assessment, a perfused variceal needle punctured each variceal column and, if low pressures fluctuating with respiration were obtained, the varix was injected. Control patients had patent varices injected based on visual assessment alone. During a mean follow-up of 13 mo (range 4-16 mo), 1 manometrically assessed patient bled once (0.002 bleeds/patient month) and 7 visually assessed patients bled 14 times from varices (0.03 bleeds/patient-month) (p less than 0.05). Two and nine episodes of ulceration occurred in manometric and visually assessed patients, respectively, (p less than 0.05). Varices were obliterated (i.e., disappeared) in 11 patients undergoing manometric assessment and in 2 patients undergoing visual assessment (p less than 0.01). Comparing results of visual and manometric assessment within "manometric" patients showed a consistent 25% error rate in diagnosing patency or thrombosis by visual assessment. Manometric assessment of varices during maintenance sclerotherapy reduces rebleeding and ulceration to very low levels.

Breast within a breast: a review of breast hamartomas.

A 22-year-old woman who presented with a large lump in the left breast, subsequently found to be a breast hamartoma, is described. A full review is given of this rare and unusual benign breast lesion, which is likely to be recognised increasingly with the advent of mammographic screening.

Malignant haemangiopericytoma of the pelvic retroperitoneum.

A case of malignant haemangiopericytoma of the pelvic retroperitoneum is described. The patient finally died of the complications of radiotherapy. In the absence of any reported long term benefits of adjuvant radiotherapy to the lesion, the lower morbidity of chemotherapy may make this form of adjuvant therapy worthy of further evaluation.

Surgery for parathyroid adenoma and hyperplasia: relationship of histology to outcome.

Recent histopathologic evidence challenges the teaching that enlargement of a solitary parathyroid gland is invariably caused by an adenoma, whereas multiple gland enlargement results from hyperplasia. We have re-examined the parathyroid tissue obtained from 152 consecutive patients undergoing surgery for primary hyperparathyroidism and compared it with their clinical outcome. Our approach was to excise enlarged glands and biopsy the remainder. In 124 patients (82%) at least three glands were biopsied or removed. The ratio of adenoma to hyperplasia was reversed by our histologic re-examination; adenomas were found in only 27 patients (25 single, two double), whereas hyperplasia was found in 117 patients (one gland, 87 patients; two glands, 16 patients; three glands, five patients; four glands, nine patients). Normal tissue only was reported in eight patients. During a 2-year follow-up, five patients (3%) developed hypocalcemia and none developed recurrent hypercalcemia. Our results indicate that a full neck exploration with removal of all enlarged glands is more important than the histologic diagnosis in planning a successful surgical strategy for primary hyperparathyroidism.