Quality of life after giant hiatus hernia repair: A systematic review.

BACKGROUND: Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH. METHODOLOGY: A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded. RESULTS: Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL. CONCLUSION: Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

Establishing spectrochemical changes in the natural history of oesophageal adenocarcinoma from tissue Raman mapping analysis.

Raman spectroscopy is a fast and sensitive technique able to identify molecular changes in biological specimens. Herein, we report on three cases where Raman microspectroscopy was used to distinguish normal vs. oesophageal adenocarcinoma (OAC) (case 1) and Barrett's oesophagus vs. OAC (cases 2 and 3) in a non-destructive and highly accurate fashion. Normal and OAC tissues were discriminated using principal component analysis plus linear discriminant analysis (PCA-LDA) with 97% accuracy (94% sensitivity and 100% specificity) (case 1); Barrett's oesophagus vs. OAC tissues were discriminated with accuracies ranging from 98 to 100% (97-100% sensitivity and 100% specificity). Spectral markers responsible for class differentiation were obtained through the difference-between-mean spectrum for each group and the PCA loadings, where C-O-C skeletal mode in ß-glucose (900 cm-1), lipids (967 cm-1), phosphodioxy (1296 cm-1), deoxyribose (1456 cm-1) and collagen (1445, 1665 cm-1) were associated with normal and OAC tissue differences. Phenylalanine (1003 cm-1), proline/collagen (1066, 1445 cm-1), phospholipids (1130 cm-1), CH2 angular deformation (1295 cm-1), disaccharides (1462 cm-1) and proteins (amide I, 1672/5 cm-1) were associated with Barrett's oesophagus and OAC tissue differences. These findings show the potential of using Raman microspectroscopy imaging for fast and accurate diagnoses of oesophageal pathologies and establishing subtle molecular changes predisposing to adenocarcinoma in a clinical setting. Graphical abstract Graphical abstract demonstrating how oesophageal tissue is processed through Raman mapping analysis in order to detect spectral differences between stages of oesophageal transformation to adenocarcinoma.

Attenuated total reflection Fourier-transform infrared spectral discrimination in human bodily fluids of oesophageal transformation to adenocarcinoma.

Diagnostic tools for the detection of early-stage oesophageal adenocarcinoma (OAC) are urgently needed. Our aim was to develop an accurate and inexpensive method using biofluids (plasma, serum, saliva or urine) for detecting oesophageal stages through to OAC (squamous; inflammatory; Barrett's; low-grade dysplasia; high-grade dysplasia; OAC) using attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy. ATR-FTIR spectroscopy coupled with variable selection methods, with successive projections or genetic algorithms (GA) combined with quadratic discriminant analysis (QDA) were employed to identify spectral biomarkers in biofluids for accurate diagnosis in a hospital setting of different stages through to OAC. Quality metrics (Accuracy, Sensitivity, Specificity and F-score) and biomarkers of disease were computed for each model. For plasma, GA-QDA models using 15 wavenumbers achieved 100% classification for four classes. For saliva, PCA-QDA models achieved 100% for the inflammatory stage and high-quality metrics for other classes. For serum, GA-QDA models achieved 100% performance for the OAC stage using 13 wavenumbers. For urine, PCA-QDA models achieved 100% performance for all classes. Selected wavenumbers using a Student's t-test (95% confidence interval) identified a differentiation of the stages on each biofluid: plasma (929 cm-1 to 1431 cm-1, associated with DNA/RNA and proteins); saliva (1000 cm-1 to 1150 cm-1, associated with DNA/RNA region); serum (1435 cm-1 to 1573 cm-1, associated with methyl groups of proteins and Amide II absorption); and, urine (1681 cm-1 to 1777 cm-1, associated with a high frequency vibration of an antiparallel ß-sheet of Amide I and stretching vibration of lipids). Our methods have demonstrated excellent efficacy for a rapid, cost-effective method of diagnosis for specific stages to OAC. These findings suggest a potential diagnostic tool for oesophageal cancer and could be translated into clinical practice.

Surgical cure for type 2 diabetes by foregut or hindgut operations: a myth or reality? A systematic review.

BACKGROUND: Bariatric surgery results in remission of type 2 diabetes mellitus in a significant proportion of patients. Animal research has proposed the foregut and hindgut hypotheses as possible mechanisms of remission of T2DM independent of weight loss. These hypotheses have formed the basis of investigational procedures designed to treat T2DM in non-obese (in addition to obese) patients. The aim of this study was to review the procedures that utilise the foregut and hindgut hypotheses to treat T2DM in humans. METHODS: A systematic review was conducted to identify the investigational procedures performed in humans that are based on the foregut and hindgut hypotheses and then to assess their outcomes. RESULTS: Twenty-four studies reported novel procedures to treat T2DM in humans; only ten utilised glycated haemoglobin A1c (HbA1c) in their definition of remission. Reported remission rates were 20-40 % for duodenal-jejunal bypass (DJB), 73-93 % for duodenal-jejunal bypass with sleeve gastrectomy (DJB-SG), 62.5-100 % for duodenal-jejunal bypass sleeve (DJBS) and 47-95.7 % for ileal interposition with sleeve gastrectomy (II-SG). When using a predetermined level of HbA1c to define remission, the remission rates were lower (27, 63, 0 and 65 %) for DJB, DJB-SG, DJBS and II-SG. CONCLUSIONS: The outcomes of the foregut- and hindgut-based procedures are not better than the outcomes of just one of their components, namely sleeve gastrectomy. The complexity of these procedures in addition to their comparable outcomes to a simpler operation questions their utility.

Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series.

Portomesenteric venous thrombosis (PMVT) is a rare but well-reported complication following laparoscopic surgery. We present three cases of PMVT following laparoscopic surgery. Our first case is a 71-year-old morbidly obese woman admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. Post-operatively, she developed multi-organ dysfunction and computed tomography scan revealed portal venous gas and extensive small bowel infarct. The second patient is a 51-year-old man with known previous deep venous thrombosis who also had elective LGHH repair. He presented 8 weeks post-operatively with severe abdominal pain and required major bowel resection. Our third case is an 86-year-old woman who developed worsening abdominal tenderness 3 days after laparoscopic right hemicolectomy for adenocarcinoma and was diagnosed with an incidental finding of thrombus in the portal vein. She did not require further surgical intervention. The current guidelines for thromboprophylaxis follow-up in this patient group may not be adequate for the patients at risk. Hence, we propose prolonged period of thromboprophylaxis in the patients undergoing major laparoscopic surgery.

Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study.

INTRODUCTION: Both converted and difficult laparoscopic cholecystectomies (LC) have impact on operating time and training of juniors. The aim of this study is to evaluate parameters that predict difficult LC or conversion (C), and find predictive values for different cut-off points of C-reactive protein (CRP) for conversion. MATERIALS AND METHODS: A retrospective cohort study of cholecystectomies performed from January 2011 to December 2012 at NHS trust was undertaken. Association of intra-operative difficulties or conversion with the following factors was studied: Age, gender, CRP, white blood cell count (WBC), history of pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Two hundred and ninety one patients were analysed (222 laparoscopic, 45 difficult LC and 24 C). Only 141 patients had a recorded CRP. Median CRP was highest for patients who were converted (286.20) compared to those who had difficult LC (67.40) or LC (7.05). Those patients who did not have preoperative CRP (8/150, 5.3%) had less chance of conversion than those who had CRP (16/141, 11.34%) (P = 0.063). Patients with CRP of ≤220 (3/91, 3.2%) had significantly less chance of conversion than those with CRP >220 (13/21, 61.9%) (P < 0.001). High preoperative CRP, WBC count and ERCP, were predictors of conversion. These factors were only marginally better than CRP alone in predicting conversion. CONCLUSION: CRP can be a strong predictor of conversion of LC. Further validation of the results is needed.

Could "Low Quality of Life" Rather Than "Significant Symptoms" Be Better Criteria for the Selection of Patients for the Repair of a Giant Hiatus Hernia?

Purpose Giant hiatus hernia (GHH) repair is undertaken electively in symptomatic patients, to prevent complications such as gastric volvulus and subsequent mortality. Advances in laparoscopy and perioperative care have reduced the risk of GHH repair, and improvement in quality of life (QoL) has become an important outcome measure. In our unit, we have been assessing QoL in all the operated as well as non-operated patients with GHH, using the "Quality of Life in Reflux and Dyspepsia" (QOLRAD) questionnaire. We sought to evaluate differences in QoL between patients who were managed conservatively for GHH and those who underwent GHH repair over a two-year period. Methods All patients seen in the Upper Gastrointestinal Tertiary Unit in Lancashire Teaching Hospitals NHS Trust with GHH between January 2015 and December 2022 were identified from a prospectively kept database. QOLRAD scores were analyzed and compared between conservatively and operatively managed patients using the Mann-Whitney U test. Demographic and operative outcome data were also collected. Results Eighty-seven patients with GHH were included. QoL of 51 patients improved significantly after elective surgery. Five out of 36 patients, who were initially treated conservatively, elected to have repair during their follow-up period. These 5 Patients had a lower initial QOLRAD score in comparison to those whose management remained conservative (2.72 vs 5.05, Mann Whitney U test p=0.034), and their QOLRAD scores also improved significantly after the operation. QOLRAD scores in conservatively managed patients remained stable over a two-year follow-up period. Conclusion Objectively calculated low QoL may be a more useful tool than subjective symptoms in selecting patients for elective repair of GHH.

Attenuated Total Reflection Fourier-Transform Infrared Spectral Discrimination in Human Tissue of Oesophageal Transformation to Adenocarcinoma.

This study presents ATR-FTIR (attenuated total reflectance Fourier-transform infrared) spectral analysis of ex vivo oesophageal tissue including all classifications to oesophageal adenocarcinoma (OAC). The article adds further validation to previous human tissue studies identifying the potential for ATR-FTIR spectroscopy in differentiating among all classes of oesophageal transformation to OAC. Tissue spectral analysis used principal component analysis quadratic discriminant analysis (PCA-QDA), successive projection algorithm quadratic discriminant analysis (SPA-QDA), and genetic algorithm quadratic discriminant analysis (GA-QDA) algorithms for variable selection and classification. The variables selected by SPA-QDA and GA-QDA discriminated tissue samples from Barrett's oesophagus (BO) to OAC with 100% accuracy on the basis of unique spectral "fingerprints" of their biochemical composition. Accuracy test results including sensitivity and specificity were determined. The best results were obtained with PCA-QDA, where tissues ranging from normal to OAC were correctly classified with 90.9% overall accuracy (71.4-100% sensitivity and 89.5-100% specificity), including the discrimination between normal and inflammatory tissue, which failed in SPA-QDA and GA-QDA. All the models revealed excellent results for distinguishing among BO, low-grade dysplasia (LGD), high-grade dysplasia (HGD), and OAC tissues (100% sensitivities and specificities). This study highlights the need for further work identifying potential biochemical markers using ATR-FTIR in tissue that could be utilised as an adjunct to histopathological diagnosis for early detection of neoplastic changes in susceptible epithelium.

The feasibility of disposable video-bronchoscopes, Ambu aScope3, for exploration of the common bile duct and extraction of stones.

Introduction: The aim of this study was to assess and evaluate the feasibility of using the Ambu aScope3 (aScope) for common bile duct (CBD) explorations, stone detection and extraction, as well as to assess feasibility of its use through the laparoscopic ports in a low-volume centre. Methods: This is a dual centre prospective study, conducted between February 2015 and August 2019, of patients undergoing laparoscopic cholecystectomy and common bile duct exploration. Ethical approval was obtained from the North West - Greater Manchester South Research Ethics Committee. All patients were counselled on the use of the aScope in clinic, prior to surgery. The Primary endpoints were the ability of the aScope to identify CBD stones, perform a cholangiogram through the available channel, retrieve the stones using a Dormia basket and to visualise second generation biliary radicles satisfactorily. The secondary endpoint was the use of the aScope, via a laparoscopic port without a gas leak. The data collected included patient demographics, need for a CBD exploration, intraoperative confirmation of CBD stones and their safe extraction using an aScope. Results: A total of nine patients were recruited. The aScope provided satisfactory views in eight of nine patients and enabled the safe extraction of CBD stones in six of nine cases. One patient had a bile leak, and another had a transected CBD prior to the use of the aScope. Conclusion: We found that the aScope is a safe, feasible alternative to a choledochoscope, and in a low-volume centre, it provides a financially viable option.

Raman spectral discrimination in human liquid biopsies of oesophageal transformation to adenocarcinoma.

The aim of this study was to determine whether Raman spectroscopy combined with chemometric analysis can be applied to interrogate biofluids (plasma, serum, saliva and urine) towards detecting oesophageal stages through to oesophageal adenocarcinoma [normal/squamous epithelium, inflammatory, Barrett's, low-grade dysplasia, high-grade dysplasia and oesophageal adenocarcinoma (OAC)]. The chemometric analysis of the spectral data was performed using principal component analysis, successive projections algorithm or genetic algorithm (GA) followed by quadratic discriminant analysis (QDA). The genetic algorithm quadratic discriminant analysis (GA-QDA) model using a few selected wavenumbers for saliva and urine samples achieved 100% classification for all classes. For plasma and serum, the GA-QDA model achieved excellent accuracy in all oesophageal stages (>90%). The main GA-QDA features responsible for sample discrimination were: 1012 cm-1 (C─O stretching of ribose), 1336 cm-1 (Amide III and CH2 wagging vibrations from glycine backbone), 1450 cm-1 (methylene deformation) and 1660 cm-1 (Amide I). The results of this study are promising and support the concept that Raman on biofluids may become a useful and objective diagnostic tool to identify oesophageal disease stages from squamous epithelium to OAC.

Biochemical investigation is no substitute for clinical examination!

CONTEXT: Toxic shock syndrome has been shown previously to be associated with hyperamylasaemia. However, serum amylase levels do not usually exceed three times upper limit of normal in these cases. CASE REPORT: We report a case of a young girl of 17 years who presented with upper abdominal pain, severe shock and raised serum amylase level of 3,898 U/L, giving an impression of severe acute pancreatitis. It was only after finding a tampon in her vagina, and subsequently growing Staphylococcus aureus in her blood cultures, did the diagnosis of toxic shock syndrome become apparent. She recovered fully with supportive treatment and appropriate antibiotics. CONCLUSIONS: Toxic shock syndrome with such a high level of serum amylase has not been previously reported. This case exemplifies the importance of repeated clinical evaluation of patients in this era of multiple investigations, and not simply relying on biochemical values for diagnosis.

Management of gastrointestinal stromal tumours in the Imatinib era: a surgeon's perspective.

BACKGROUND: Surgical resection has remained the mainstay of treatment of GIST with a 5-year-survival of 28-35%. Tyrosine kinase inhibitor (Imatinib) has revolutionised the treatment of these tumours. The current research is directed towards expanding the role of this drug in the treatment of GIST. We present our experience of managing GIST in this institute. METHODS: This is a case note study of patients identified from a prospectively kept database from January 2000 to August 2007. RESULTS: 16 patients were diagnosed with GIST. The median age was 66 years (range 46 to 82) and the male to female ratio was 9:7. Eleven patients underwent surgery, 9 of which had R0 resection (2 laparoscopic, 1 converted to open), one had an open biopsy and one had a debulking procedure. 3 patients were inoperable and 2 were found to be unfit for surgery. Five patients received Imatinib (2 postoperatively). The risk assessment based on morphological criteria showed that 4 patients had low, 4 had intermediate and 8 had high malignant potential. The median follow up was for 12 months (range 3-72); 2 patients died of unrelated causes at 6 and 9 months after diagnosis. CONCLUSION: Most GISTs can be managed effectively using existing protocols. However currently there is no evidence based guidance available on the management of GIST in the following situations-role of debulking surgery, the follow up of benign tumours not requiring surgical resection and role of laparoscopic surgery. Further research is needed to answer these questions.

Radiofrequency ablation of the pancreas. II: Intra-operative ablation of non-resectable pancreatic cancer. A description of technique and initial outcome.

CONTEXT: There is little reported experience of radiofrequency ablation of pancreatic tumours. Our group has reported the development of a porcine pancreatic model of radiofrequency ablation of the pancreas. This brief report details the application of this technique to clinical practice. CASE REPORT: A 58-year-old man with metastatic pancreatic tumour underwent operative radiofrequency ablation. An operative approach was utilised to protect the stomach and transverse colon and also to prevent thermal injury to the inferior vena cava. In addition, the operative technique was combined with prophylactic hepaticojejunostomy and gastrojejunostomy to anticipate ablation-related biliary injury or duodenal stenosis. A post-ablation CT scan two weeks after the procedure confirmed radiological evidence of ablation. The patient remained well until his death, 3 months after surgery. CONCLUSION: This report demonstrates that operative radiofrequency ablation is feasible and was safely carried out in this case. More experience is required to assess the spectrum of complications and if there is true oncological efficacy.

Radiofrequency ablation of the pancreas. I: Definition of optimal thermal kinetic parameters and the effect of simulated portal venous circulation in an ex-vivo porcine model.

CONTEXT: Radiofrequency ablation of pancreatic tumours carries a risk of injury to important structures such as the bile duct and duodenum. We have recently developed an ex-vivo model of radiofrequency ablation of the porcine pancreas. OBJECTIVE: This study evaluates the effect of variations in probe temperature, duration of ablation and simulated portal venous flow on radiofrequency-induced injury. SPECIMEN RETRIEVAL: Pancreata of 30 6-month-old healthy pigs undergoing sacrifice in a commercial abattoir were used. INTERVENTIONS: Radiofrequency energy was applied to a pre-marked area of the pancreatic head. Pancreatic head biopsies were taken after ablation to incorporate duodenum, portal vein and bile duct respectively and frozen in liquid nitrogen. For each experiment a portion of the tail of the pancreas was studied as non-ablated control. Paired slides using haematoxylin and eosin (H&E) and nicotinamide adenine dinucleotide (NADH) stains were prepared. MAIN OUTCOME MEASURES: The effects of variation in target temperature (100 degrees C to 80 degrees C), duration of ablation and of simulated portal perfusion were studied. RESULTS: Optimal thermal kinetic characteristics were produced by a target temperature of 90 degrees C applied for 5 minutes. At this temperature there was ablation of pancreas without injury to adjacent viscera. Higher temperatures resulted in injury to the bile duct and portal vein. Simulated portal circulation had no effect on ablation. CONCLUSIONS: In this ex-vivo study radiofrequency produced a temperature and duration dependent ablation with the optimal characteristics being 90 degrees C for 5 minutes.