Impact of Toupet Versus Nissen Fundoplication on Dysphagia in Patients With Gastroesophageal Reflux Disease and Associated Preoperative Esophageal Dysmotility: A Systematic Review and Meta-Analysis.

BACKGROUND: Controversy exists regarding the best surgical approach for the management of gastroesophageal reflux disease (GORD) and associated preoperative esophageal dysmotility. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes of Toupet fundoplication (TF) and Nissen fundoplication (NF) in patients with GORD and coexistent preoperative esophageal dysmotility. METHODS: We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov , and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Postoperative dysphagia and improvement in dysphagia were primary outcome parameters. RESULTS: We identified 3 randomized controlled trials and 1 observational study reporting a total of 220 patients, of whom 126 underwent TF and the remaining 94 patients had NF. Despite the existence of significantly higher preoperative dysphagia in the TF group (29.3% vs 4.2%, P = .05), TF was associated with significantly lower postoperative dysphagia (odds ratio [OR] = 0.31, P = .002) with low between-study heterogeneity ( I2 = 11%, P = .34), and significantly higher improved dysphagia (OR = 10.32, P < .0001) with moderate between-study heterogeneity ( I2 = 31%, P = .23) compared with NF. CONCLUSION: TF may be associated with significantly lower postoperative dysphagia than NF in patients with GORD and associated preoperative esophageal dysmotility. However, no definite conclusions can be drawn as the best available evidence comes mainly from a limited number of heterogeneous randomized controlled trials. Future studies are encouraged to include patients with similar preoperative dysphagia status and report the outcomes with respect to recurrence of acid reflux symptoms.

Irrigation Versus Suction Alone in Laparoscopic Appendectomy: Is Dilution the Solution to Pollution? A Systematic Review and Meta-Analysis.

OBJECTIVES: To investigate outcomes of peritoneal irrigation versus suction without irrigation in patients undergoing emergency laparoscopic appendectomy. METHODS: We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) and observational studies investigating outcomes of irrigation versus suction alone in patients undergoing emergency laparoscopic appendectomy. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. RESULTS: We identified 3 RCTs and 2 retrospective observational studies, enrolling 2511 patients. Our results suggested that there was no difference between peritoneal irrigation and suction alone in terms of intraabdominal abscess rate (odds ratio = 2.39, 95% confidence interval [CI] = 0.49-11.74, P = .28), wound infection (risk difference = 0.00, 95% CI = -0.04 to 0.05, P = .85), and length of stay (mean difference = -1.02, 95% CI = -3.10 to 1.07, P = .34); however, peritoneal irrigation was associated with longer operative time (mean difference = 7.12, 95% CI = 4.33 to 9.92, P < .00001). Our results remained consistent when randomized trials, adult patients, and pediatric patients were analyzed separately. CONCLUSIONS: The best available evidence suggests that the peritoneal irrigation with normal saline during laparoscopic appendectomy does not provide additional benefits compared with suction alone in terms of intraabdominal abscess, wound infection, and length of stay but it may prolong the operative time. The quality of the best available evidence is moderate; therefore, high-quality RCTs, which are adequately powered, are required to provide more robust basis for definite conclusions.

Laparoscopic correction of intestinal malrotation in adult.

Intestinal malrotation is rare in adults. Patients may present with acute obstruction or chronic abdominal pain. These symptoms are caused by Ladd's bands and narrow mesentery resulting from incomplete gut rotation. Barium, computed tomography (CT) and magnetic resonance imaging (MRI), angiography and sometimes explorative laparotomy are used for diagnosis. Ladd's procedure is the treatment of choice but data about laparoscopic approach in adult is scarce. We report three cases of laparoscopic correction of adult malrotation presenting with chronic abdominal pain. The diagnosis is made by CT/MRI. Laparoscopic Ladd's procedure (release of bands, broadening of mesentery and appendicectomy) was performed via three ports. Procedure time 25-45 min. All patients were discharged on postoperative day 2. At 6 month follow-up, all are symptom free. Laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating chronic symptoms of intestinal malrotation in adults.

Laparoscopic management of post-cholecystectomy sectoral artery pseudoaneurysm.

Vascular injuries during laparoscopic cholecystectomy can occur similar to biliary injuries and mostly represented by intraoperative bleeding. Hepatic artery system pseudoaneurysm are rare. It occurs in the early or late postoperative course. Patients present with pallor, signs of haemobillia and altered liver function. We report a case of right posterior sectoral artery pseudoaneurysm detected 2 weeks after laparoscopic cholecystectomy and successfully repaired laparoscopically. We also describe how laparoscopic pringle clamping saved the conversion. The actively bleeding right posterior sectoral artery pseudoaneurysm was diagnosed by CT angiogram. Embolisation, usually the treatment of choice, would have risked liver insufficiency as hepatic artery proper was at risk because the origin the bleeding artery was just after its bifurcation. Isolated right hepatic artery embolisation can also cause hepatic insufficiency. To our knowledge this is the first reported case of laparoscopic repair of post-laparoscopic cholecystectomy bleeding sectoral artery pseudoaneurysm.

Wilkie's syndrome: review of eight cases.

BACKGROUND: The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and abrupt weight loss. Usually seen in tall individual with low bod mass index (BMI), the weight loss may be primary or secondary to a systemic disease or to the syndrome itself Compression of the duodenum between the abdominal aorta and the superior mesenteric artery due to loss of the duodenal pad of fat causes the obstruction. Early recognition prevent complications. Imaging and endoscopy is diagnostic. Aorto-mesenteric angle and SMA aorta distance is lower than 22 degree and eight millimeter respectively. If nutritional support fails, surgery is required (e.g. guodeno-jejunostomy). Studies to determine the optimal methods of diagnosis and treatment, especially in a suburban hospitals with limited expertise are essential. CASE REPORT: We retrospectively evaluated 8 cases presented over three years. Six (75%) patients were males, age ranged from 19 to 70 years and weight from 40 to 55 kg. The mean BMI was 18.7 kg/ m2 (range 16.42 to 25.11 kg/m2). Mean weight loss before diagnosis was 9.88 kg (range 6 to 12 kg). Symptoms developed between 8 to 180 days (median 12 days). Commonest presentation was epigastric pain, vomiting and nausea. Four patients had pre-morbid conditions and the syndrome was idiopathic in the other 4. Median aorto-mesentric angle was 16.5 degree and SMA-aorta distance was 5.15 mm. Four patients required operation. The rest improved on conservative treatment. CONCLUSION: Early recognition, institution of the appropriate conservative measures and timely selection of a definite surgical method are critical to prevent severe complications and death.

Operative versus non-operative management of adhesive small bowel obstruction: A systematic review and meta-analysis.

OBJECTIVES: To investigate outcomes of operative and non-operative management of adhesive small bowel obstruction (SBO). METHODS: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. We conducted a search of electronic information sources to identify all randomised controlled trials (RCTs) and observational studies investigating outcomes of operative versus non-operative management of patients with adhesive SBO. We used the Cochrane risk of bias tool and the Newcastle-Ottawa scale to assess the risk of bias of RCTs and observational studies, respectively. Fixed-effect or random-effects models were applied to calculate pooled outcome data. RESULTS: We found one RCT, two prospective and three retrospective observational studies, enrolling a total of 876 patients. The analyses showed that operative management of adhesive SBO was associated with a lower risk of future recurrence [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.38-0.76, P = 0.0005] but a higher risk of mortality [risk difference (RD) 0.03, 95% CI 0.01-0.06, P = 0.01] and complications (OR 5.39, 95% CI 2.97-9.78, P < 0.00001). There was no difference in need for surgical re-intervention rate (OR 0.72, 95% CI 0.35-1.47, P = 0.36) and length of stay [mean difference (MD) 5.07, 95% CI -2.36-12.49, P = 1.0] between operative and non-operative managements. The baseline suspicion of strangulation was a major confounding factor. When the baseline suspicion of strangulation was higher in the operative group, the risk of mortality (RD 0.04, 95% CI 0.02-0.07, P = 0.0006) and complications (OR 8.14, 95% CI 4.16-15.94, P = 0.00001) were higher in the operative group but the risk of recurrence was lower (OR 0.62, 95% CI 0.43-0.90, P = 0.01). When the baseline suspicion of strangulation was low in both groups, there was no difference in any of the outcomes except recurrence (OR 0.09, 95% CI 0.02-0.37, P = 0.0009) which was lower in the operative group. CONCLUSIONS: The difference in baseline suspicion of strangulation between operative and non-operative groups is a major confounding factor in current literature. The benefit of surgical treatment should be balanced with the risks associated with surgery, patient's co-morbidities, and presence or absence of strangulation. Based on the best available evidence it could be argued that surgical intervention could be preserved for cases with high suspicion or evidence of bowel strangulation. The controversy still remains for optimum length of conservative management and timing of surgery (early or late) for cases with low baseline suspicion of strangulation. Randomised controlled trials are required to compare outcomes of early operation (<24 h) versus late operation (>24 h) and early operation versus conservative management in patients with low suspicion of strangulation.

Retropancreatic Ovarian Tumor.

Retroperitoneal mucinous cystadenomas are rare lesions (less than 50 reported) characterized by presence of ovary like stroma of unknown origin. However, germinal component of ovary has never been found in them. The pancreas occasionally gives rise to mucinous cystadenomas, but they are always intrapancreatic. We report a unique case of a rare retroperitoneal mucinous cystadenomas with presence of ovarian follicles in a 45-year-old lady who presented with an abdominal mass. This was successfully excised. Though retroperitoneal mucinous cystadenomas are rare, presence of ovarian follicle (germ cell) in them has never been reported before.

Spleen-Preserving Versus Spleen-Sacrificing Distal Pancreatectomy in Laparoscopy and Open Method-Perioperative Outcome Analysis-14 Years Experience.

We analyzed perioperative outcome of distal pancreatectomies with or without splenic preservation both in laparoscopic and open method to determine best approach. Retrospective data was collected from 1999 to 2013. We divided all distal pancreatectomies into four groups. Group 1-laparoscopic spleen-preserving distal pancreatectomy (LSPDP). Group 2-laparoscopic splenectomy + distal pancreatectomy (LSDP). Group 3-open spleen-preserving distal pancreatectomy. Group 4-open splenectomy + distal pancreatectomy. We recorded demographic data, intra and post operative complications, operative time, estimated blood loss, length of stay, pancreatic leak rate, and final pathology result. A total of 38 distal pancreatectomies were included. In group 1, patients were significantly younger (mean 29 vs 47 to 50 in other groups, p = 0.014). Tumor size (average 2.5 vs 5 to 9.5 cm in other groups, p = 0.023) and operative time (average 98 min vs 125 to 141 in other groups, p = 0.004) and hospital stay (average 6 vs 8 to 19 days in other groups, p = 0.009) in LSPDP were all significantly less than other groups taken together. However, intra-operative blood loss was equivalent. We further analyzed that between LSPDP and LSDP, age and tumor size were significantly less in LSPDP. Further we analyzed between spleen-preserving (groups 1 + 3) vs spleen-sacrificing (groups 2 + 4) distal pancreatectomies and between overall laparoscopic (groups 1 + 2) vs open (groups 3 + 4). Laparoscopic spleen-preserving distal pancreatectomy has all the advantages of minimal access surgery especially in small lesions and low-grade malignancy.

Laparoscopic Esophagogastroplasty in Management of Megaesophagus with Axis Deviation.

The results of cardiomyotomy in patients of achalasic megaesophagus with axis deviation are not satisfactory. Usually, an esophagectomy is advocated. We describe the technical details and outcomes of laparoscopic esophagogastroplasty for end-stage achalasia. The patient had end-stage achalasia, characterized by tortuous megaesophagus with axis deviation. The surgery was performed in supine position using four abdominal ports. The steps included mobilization of the gastroesophageal junction and lower intrathoracic esophagus, straightening the pulled intrathoracic esophagus into the abdomen, and a side-side esophagogastroplasty using purple Endo GIA Articulating Tri-Staple load, two firings. Duration of surgery was 52 min. The patient was ambulated on the first postoperative day. Oral feeding was initiated by the third postoperative day. The patients had significant improvements of dysphagia. At 3 months of follow-up, the patient is euphagic without significant symptoms of gastroesophageal reflux. Laparoscopic esophagogastroplasty is an effective option for relieving dysphagia in megaesophagus due to achalasia with axis deviation. It is a reasonable alternative before subjecting to a major and potentially morbid esophagectomy. It creates a large gastroesophageal (GE) junction, which, with the help of gravity, helps food transit. By dividing the muscles of the GE junction completely, it also achieves a complete cardiomyotomy. Less operative time and blood loss, quicker recovery, and better cosmesis make it an attractive option. While potential reflux is a possibility, the reported case has not shown significant GERD symptoms.

Retroperitoneal Sarcoma. Outcome Analysis in a Teaching Hospital in Eastern India- a Perspective.

Primary Retroperitoneal Sarcomas are relatively uncommon tumors with varied manifestations, ill-defined prognostic factors and uncertain management modalities. We undertook this study to review patients who presented with primary or recurrent RPS at our institute during the study period. Between 2008 and 2010, 23 patients were evaluated. Statistical analysis was done using the chi square test or Fisher's exact test. Recurrence was calculated using Kaplan Meier curves. The log-rank test was used to compare differences in survival or relapse. Among the 23 patients, 13 were males. Majority (52.2 %) presented with abdominal lump located in umbilical and right hypochondrial region. Surgery was done in 20 (87 %) patients for primary RPS and three (13 %) for recurrent RPS at initial presentation. 14 (61 %) received complete tumor resection, six (27 %) incomplete microscopic resection, and three (13 %) incomplete macroscopic resection. In univariate Cox's proportional hazard model on time ('timer') to event ('relapse') analysis, all the variables like older age (p = 0.027), male sex (p = 0.012), incomplete resection (p = 0.008), large size (0.047) and high grade (p = 0.047) became significant predictor of early recurrence. However, multivariate analysis showed that only extent of resection, grade and sex were statistically significant predictors. Complete tumor resection of retroperitoneal sarcoma (n = 14) was associated with a significantly lesser recurrence compared with unclear resection (n = 9, p = 0.002). The median time between surgery and first recurrence was 15 months. High-grade sarcomas had a significantly higher recurrence (n = 10; median: 24, 95 % CI) than low-grade sarcomas (n = 13, median: 15; 95 %CI P < 0.01). Furthermore, the survival of male patients were worse than that of females (p = 0.036). Completeness of resection, tumor grade and sex are prognostic factors of retroperitoneal soft tissue sarcomas.

Epidemiological factors in gall bladder cancer in eastern India-a single centre study.

India has high incidence of Gallbladder carcinoma with regional variation in incidence possibly due to environmental factors. Prospective study of all the gall bladder cancer in our hospital over 18 months analysing how the epidemiological factors are influencing the disease. Incidence-Four cases per 100,000 populations per year. The peak incidence was in 41 to 50 years group (49.20 %). Male to female ratio was 1:3.8. Majority (69.84 %) were in lower socio-economic group. 61 out of 63 patients (96.62 %) were non-vegetarians. 60.34 % and 19.04 % patients weighed between 50 and 55 kg and 55and 60 kg respectively (p = 0.003). Male smokers had significantly higher risk (p = 0.000 1). Gall stones were present in 45 out of 63 cases(71.42 %).45 out of 63 patients were typhoid carriers (p < 0.05). Pain abdomen was the commonest complaint (87.30 %), followed by pallor, lump in right upper quadrant, nausea & vomiting and jaundice in 71.42 %, 69.84 %, 66.66 %, 31.74 % patients respectively. This data highlights high prevalence of gall bladder carcinoma in Eastern India. Better hygiene and water supply to prevent typhoid carriers, prevention of malnutrition, early intervention for cholelithiasis, importance of balanced diet, increase in awareness about risk of tobacco and alcohol consumption-all are highlighted as significant modifiable factors.

Is immediate postoperative CA15.3 assay a predictive marker of early postoperative recurrence of carcinoma breast?

Breast cancer is still an enigma. Systemic metastasis is an important prognostic factor. Tumour marker can predict occult systemic metastasis. To evaluate the immediate postoperative CA15.3 as predictor of early recurrence, a study was carried out in 48 patients of carcinoma breast in whom immediate postoperative marker level was done. In follow-up, recurrence was noted and relation with tumour size and stage done. Null hypothesis and 't' test were used for analysis. Relation of tumour size with marker is weak but strong relation exists between tumour stage with marker and recurrence with marker. CA15.3 predicts tumour load, can also predict occult residual/occult metastatic disease better than other prognostic markers which only predict tumour behaviour.

Wilkie’s syndrome: review of eight cases / Wilkie’s syndrome: review of eight cases.

BACKGROUND: The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and abrupt weight loss. Usually seen in tall individual with low bod mass index (BMI), the weight loss may be primary or secondary to a systemic disease or to the syndrome itself Compression of the duodenum between the abdominal aorta and the superior mesenteric artery due to loss of the duodenal pad of fat causes the obstruction. Early recognition prevent complications. Imaging and endoscopy is diagnostic. Aorto-mesenteric angle and SMA aorta distance is lower than 22 degree and eight millimeter respectively. If nutritional support fails, surgery is required (e.g. guodeno-jejunostomy). Studies to determine the optimal methods of diagnosis and treatment, especially in a suburban hospitals with limited expertise are essential. CASE REPORT: We retrospectively evaluated 8 cases presented over three years. Six (75

) patients were males, age ranged from 19 to 70 years and weight from 40 to 55 kg. The mean BMI was 18.7 kg/ m2 (range 16.42 to 25.11 kg/m2). Mean weight loss before diagnosis was 9.88 kg (range 6 to 12 kg). Symptoms developed between 8 to 180 days (median 12 days). Commonest presentation was epigastric pain, vomiting and nausea. Four patients had pre-morbid conditions and the syndrome was idiopathic in the other 4. Median aorto-mesentric angle was 16.5 degree and SMA-aorta distance was 5.15 mm. Four patients required operation. The rest improved on conservative treatment. CONCLUSION: Early recognition, institution of the appropriate conservative measures and timely selection of a definite surgical method are critical to prevent severe complications and death.

Wilkies syndrome: review of eight cases. / Wilkies syndrome: review of eight cases.

BACKGROUND: The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and abrupt weight loss. Usually seen in tall individual with low bod mass index (BMI), the weight loss may be primary or secondary to a systemic disease or to the syndrome itself Compression of the duodenum between the abdominal aorta and the superior mesenteric artery due to loss of the duodenal pad of fat causes the obstruction. Early recognition prevent complications. Imaging and endoscopy is diagnostic. Aorto-mesenteric angle and SMA aorta distance is lower than 22 degree and eight millimeter respectively. If nutritional support fails, surgery is required (e.g. guodeno-jejunostomy). Studies to determine the optimal methods of diagnosis and treatment, especially in a suburban hospitals with limited expertise are essential. CASE REPORT: We retrospectively evaluated 8 cases presented over three years. Six (75

) patients were males, age ranged from 19 to 70 years and weight from 40 to 55 kg. The mean BMI was 18.7 kg/ m2 (range 16.42 to 25.11 kg/m2). Mean weight loss before diagnosis was 9.88 kg (range 6 to 12 kg). Symptoms developed between 8 to 180 days (median 12 days). Commonest presentation was epigastric pain, vomiting and nausea. Four patients had pre-morbid conditions and the syndrome was idiopathic in the other 4. Median aorto-mesentric angle was 16.5 degree and SMA-aorta distance was 5.15 mm. Four patients required operation. The rest improved on conservative treatment. CONCLUSION: Early recognition, institution of the appropriate conservative measures and timely selection of a definite surgical method are critical to prevent severe complications and death.