Expert Recommendations on Optimizing the Diagnosis and Management of Gastroesophageal Reflux Disease Associated with Comorbidities in the Indian Population.

Gastroesophageal reflux disease (GERD) is among the most prevalent gastrointestinal (GI) disorders. It is known to often coexist with other chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD), obesity, diabetes mellitus (DM), and hypertension. Upper endoscopy, esophageal manometry, and impedance-pH monitoring are a few invasive diagnostic options that are reserved for selected GERD patients. Symptom assessment by using questionnaires, such as the frequency scale for the symptoms of GERD (FSSG), is simple, convenient, noninvasive, and inexpensive. These questionnaires are widely used to facilitate diagnosis and appropriate treatment. Early diagnosis of GERD and timely management may improve clinical outcomes in patients. Proton pump inhibitors (PPIs) are the preferred therapy for GERD. However, evidence indicates that excessive and extended use of PPIs is linked to adverse events. An overview of the diagnosis and management of GERD, as well as an evidence-based overview of the relationship between GERD and asthma, COPD, obesity, DM, and hypertension, is presented in this review. Expert opinions and recommendations for diagnosing GERD using invasive tests and validated questionnaires have also been mentioned.

Outcomes of Sciatic Nerve Injury Repairs: A Systematic Review.

Background: The objective of this study was to investigate the surgical repair techniques and the outcomes of sciatic nerve injuries in traumatic wounds. Methods: A literature search was conducted using the following keywords:sciatic, nerve, repair, technique, conduit, graft, reconstruction, outcome, rehabilitation, recovery, function, surgery, and NOT anesthesia. Results: In total, 715 studies were retrieved. After abstract review, 13 articles fit the criteria. A total of 2627 repairs were carried out, including nerve grafts (n = 953), suture (n = 482), and neurolysis (n = 1192). Six studies reported good motor outcome, and good sensory outcome was reported across 2 studies. The thigh region accounted for 81.5% of lesions. Sciatic, peroneal, and tibial nerves were all equally affected. Gunshot wounds were the most common mechanism of injury (22.6%). Conclusions: The cumulative evidence demonstrates sciatic nerve injury repair has poor motor and sensory outcomes. This study shows there is a lack of standardized outcome measures, making comparisons very difficult. Graft lengths of <4 cm within the intermediate region yielded more successful outcomes. Further higher quality studies of nerve transfers in the lower limbs are needed to determine the optimal repair to restore sciatic nerve function.

A Quality Improvement Project to Improve the Pathway and Outcomes for Patients with Necrotising Fasciitis.

Background: Necrotising fasciitis (NF) is a life-threatening illness that requires a multidisciplinary approach between surgeons in multiple specialties, intensivists, and microbiologists. Serial debridements and change of dressings are required prior to reconstruction. The aim of this study was to review the workload and streamline services in a tertiary centre for regional and internal referrals by formalizing an NF pathway agreed upon by all multidisciplinary team stakeholders and securing adequate resources for these complex patients. Methods: Retrospective data was collected on all patients with NF referred to the plastic surgery department between January 2017 and September 2018. Referrals were categorized as either regional (debridement had already taken place at another hospital) or internal (conducted on patients admitted through the emergency department). Results: A total of 41 patients (17 regional and 24 internal referrals) with a median age of 63 years (range, 28 to 85 years) were included in the study. Overall mortality rate was found to be 27%, median length of stay (LOS) amongst internal referrals was 25 days (range, 11 to 94 days), and median intensive care unit LOS was 8 days (range, 0 to 64 days). A total of 121 operations were conducted by 4 surgical specialties with a median time per procedure of 145 minutes (range, 50 to 605). 11 patients underwent reconstruction with split thickness graft and the median number of days between initial debridement to grafting was 13 (range, 2 to 38 days). Conclusions: Patients with NF require complex care and treatment. By characterizing and defining the workload involved in treating these patients, it may be possible to improve advanced planning and allocate resources accordingly to ensure that the centre runs as smoothly as possible without interruption to the acute trauma service.

Systematic Review of Free Tissue Transfer Used in Pediatric Lower Extremity Injuries.

Aims: To analyze the recent literature regarding the different types of free tissue transfer used in pediatric lower-limb trauma, trends, flap success rates, and the anatomical location of reconstruction. Method: A search was conducted involving the MEDLINE database using the key words "Paediatric," "Pediatric," "Children," "Lower limb," "Lower extremity," "Leg," "Ankle," "Foot," "Free flap," "Flap," "Microsurgery," and "Free tissue transfer" in a 3-component search applying the Boolean operators "OR" and "AND." The search was condensed to articles published in the last 5 years. Results: In total, 240 studies were retrieved. Thirty-nine titles were selected and after reviewing the abstracts, 10 articles fit the inclusion and exclusion criteria. A total of 220 free flaps were used to reconstruct defects. Age range was between 2 and 17 years. Complete flap failure rate was 4.5% (n = 10). The anterolateral thigh perforator flap was the commonest flap used (n = 59), and the latissimus dorsi flap was the commonest muscle flap used (n = 51). Sixty-five percent of flaps were fasciocutaneous/perforator, while muscle flaps accounted for only 33% of flaps. The foot and ankle region accounted for 72% of defects. Conclusion: With evidence of improved success rates, free tissue transfer has become a popular choice in reconstruction of pediatric lower-limb trauma injuries. This study shows that perforator/fasciocutaneous flaps have recently become a more popular choice over muscle flaps. Overall, the success rate of free flaps in pediatric lower-limb trauma is high (95.5%) and comparable with the adult population.

A Quality Improvement Project to Improve the Pathway and Outcomes for Patients with Necrotising Fasciitis.

Background: Necrotising fasciitis (NF) is a life-threatening illness that requires a multidisciplinary approach between surgeons in multiple specialties, intensivists, and microbiologists. Serial debridements and change of dressings are required prior to reconstruction. The aim of this study was to review the workload and streamline services in a tertiary centre for regional and internal referrals by formalizing an NF pathway agreed upon by all multidisciplinary team stakeholders and securing adequate resources for these complex patients. Methods: Retrospective data was collected on all patients with NF referred to the plastic surgery department between January 2017 and September 2018. Referrals were categorized as either regional (debridement had already taken place at another hospital) or internal (conducted on patients admitted through the emergency department). Results: A total of 41 patients (17 regional and 24 internal referrals) with a median age of 63 years (range, 28 to 85 years) were included in the study. Overall mortality rate was found to be 27%, median length of stay (LOS) amongst internal referrals was 25 days (range, 11 to 94 days), and median intensive care unit LOS was 8 days (range, 0 to 64 days). A total of 121 operations were conducted by 4 surgical specialties with a median time per procedure of 145 minutes (range, 50 to 605). 11 patients underwent reconstruction with split thickness graft and the median number of days between initial debridement to grafting was 13 (range, 2 to 38 days). Conclusions: Patients with NF require complex care and treatment. By characterizing and defining the workload involved in treating these patients, it may be possible to improve advanced planning and allocate resources accordingly to ensure that the centre runs as smoothly as possible without interruption to the acute trauma service.

Recent advances in therapeutic bronchoscopy.

Therapeutic bronchoscopy has come a long way from removal of foreign bodies to minimally invasive techniques in management of diseases like lung cancer, chronic obstructive pulmonary disease and asthma. This article discusses the exciting new techniques of therapeutic bronchoscopy namely; bronchoscopic lung volume reduction, bronchial thermoplasty, radiofrequency ablation, and use of fiducial markers in external beam irradiation.