Laparoscopic paraoesophageal hernia repair: fundoplication is not usually indicated

BACKGROUND

Paraoesophageal hernias are an uncommon but important diaphragmatic defect due to a high prevalence of associated complications. The advent of laparoscopic surgery has popularised the surgical management of this condition, although the optimal technique has yet to be defined. The aim of this cohort study was to assess the necessity of an anti-reflux procedure in addition to the crural repair.

METHODS

Details of all patients undergoing laparoscopic paraoesophageal hernia repair were collected prospectively paying particular attention to the details of the operative procedure and outcome, including the development of early complications. All patients were followed for six months and symptoms related to hernia recurrence or technical failure including dysphagia and reflux were noted.

RESULTS

Twenty-three consecutive patients underwent laparoscopic paraoesophageal hernia repair. The first 11 patients (Group 1) routinely underwent an additional anti-reflux procedure, whereas the later cohort (Group 2) did not (chi-squared P<0.05). At six months, nine of eleven patients in Group 1 reported dysphagia, in two cases requiring dilatation, but this complication was not seen in those in Group 2. Two patients reported reflux at six-month follow-up; this was controlled in both cases by a low dose of a proton pump inhibitor.

CONCLUSION

Laparoscopic repair of paraoesophageal hernias is an effective treatment with excellent short-term results and no recurrences. Our experience would suggest that an anti-reflux procedure is not always indicated and may indeed be detrimental to symptomatic outcome.

Self-expanding metal stents for duodenal obstruction in advanced pancreatic adenocarcinoma

INTRODUCTION

Gastric outlet obstruction (GOO) is a frequent feature of advanced pancreatic carcinoma. Self-expandable metal stents (SEMS) allow the condition to be managed outside by endoscopy rather than surgical bypass. The aim of this study is to report our experience in a district general hospital with SEMS for palliation of pancreatic carcinoma-related GOO.

PATIENTS AND METHODS

All patients admitted with or developing GOO secondary to pancreatic adenocarcinoma between January 2004 and December 2005 were identified. Notes were retrieved to determine the efficacy of stenting including: complications of the procedure, length of stay, readmissions and long-term patency.

RESULTS

Of 39 new cases of pancreatic cancer, 9 patients presented with (n=6) or developed (n=3) duodenal obstruction. In one patient, previous gastric surgery restricted access. Stenting was attempted in 8 patients (4 M and 4 F) with a mean age of 63 years (range 42-76 years). In one case, the duodenal invasion was too extensive to allow passage of the guide-wire and open bypass was performed. Stenting was successful in the remaining seven patients with no early complications. The median hospital stay post-procedure was 7 days (range 5-11 days). One patient was re-admitted after 11 weeks with recurrent duodenal obstruction and a second stent was placed. The median survival post-stenting was 10 weeks (range 3-28 weeks).

CONCLUSIONS

SEMS allows patients to leave hospital quickly and return to daily activities, albeit for the short term. The procedure requires an experienced interventional endoscopist but can be accomplished safely in the DGH setting.

Hepatic complications following preoperative chemotherapy with oxaliplatin or irinotecan for hepatic colorectal metastases

AIMS

The aim of this article is to review the current state of knowledge in relation to the development of chemotherapy associated steatohepatitis (CASH) and sinusoidal obstruction syndrome (SOS) occurring following the administration of irinotecan and oxaliplatin respectively to patients with colorectal liver metastases and also to highlight potential concerns relating to other new agents.

METHODS

An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles related to the incidence, aetiology, pathology and effects of CASH and SOS outcome in patients undergoing hepatic resection.

RESULTS

CASH and SOS are relatively common findings in liver resection specimens following the administration of irinotecan and oxaliplatin-based regimes being reported in up to 50% and 20% of cases respectively. Whilst the aetiology and pathological changes are well-described, the relationship between the presence of these pathologies and outcomes is less well defined. The data in relation to SOS following oxaliplatin is limited but there may be an increased morbidity associated with the presence of SOS. There is significantly more evidence that the presence of CASH is associated with an increased morbidity and possibly mortality following hepatic resection as a result of the development of liver failure. Further studies are required to clarify these early observations.

CONCLUSIONS

The frequent identification of distinct pathological entities in association with oxaliplatin and irinotecan chemotherapy means that patients undergoing liver resection following treatment with these agents should be carefully monitored to accurately determine the morbidity and mortality attributable to the use of these agents. Furthermore, additional studies are required to clarify risk factors for the development of CASH and SOS so that certain regimens can be avoided in at risk populations thus reducing hepatic damage and increasing the chances of cure and survival following liver resection.

Haemorrhage following pancreaticoduodenectomy: risk factors and the importance of sentinel bleed

AIM

To document the prevalence and to evaluate the management strategies of haemorrhagic complications following pancreaticoduodenectomy (PD).

METHODS

All patients who underwent PD from 1/2000 to 10/2005 and experienced at least one episode of haemorrhage during the 30 first days postoperatively were recorded. Etiology of haemorrhage, treatment strategy and mortality rate were recorded and analyzed.

RESULTS

A total of 362 patients underwent PD during this period and 32 (8.8%) had haemorrhage postoperatively of whom 15 died (47% mortality rate). Primary intraluminal haemorrhage was recorded in 13 patients, primary intra-abdominal haemorrhage in 5 patients and secondary haemorrhage in 14 patients. Successful management of haemorrhage with angioembilization occurred in 2 patients in the study group. Statistical analysis revealed sepsis and sentinel bleed as risk factors for post-PD haemorrhage and pancreatic leak and sentinel bleed as risk factors for secondary haemorrhage (p < 0.05).

CONCLUSIONS

Haemorrhage after PD is a life-threatening complication. Sepsis, pancreatic leak, and sentinel bleed are statistical significant factors predicting post-PD haemorrhage. Sentinel bleed is not statistically significant associated with postoperative mortality, but with the onset of secondary haemorrhage. The effectiveness of therapeutic angioembolization was not demonstrated in our study.

Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting

INTRODUCTION

The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by 'untrained' junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by 'experienced' house surgeons during the month of July and by the 'novices' during August.

PATIENTS AND METHODS

All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR).

RESULTS

During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs.

CONCLUSIONS

We have demonstrated that the popular myth of the 'August syndrome' is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.

Gastro-colonic anastomosis--a viable option in extensive small bowel infarction

INTRODUCTION

We have previously presented a patient with massive small and large bowel infarction and demonstrated that even with only a few inches of remaining small bowel an almost normal life-style and diet is possible.

PATIENT

Recently, we have looked after a young and otherwise fit female patient who suffered mesenteric venous gangrene of the whole small bowel from the Ligament of Treitz to the caecum. In order to achieve gastro-intestinal continuity and to avoid the torrential fluid loss associated with high fistula, an anastomosis between the stomach and the transverse colon was formed.

RESULTS

We are surprised to find that despite the extensive resection our patient maintains a good quality of life and is able to look after her young family.

Autoimmune pancreatitis: an underdiagnosed condition in Caucasians

Unlike in Japan, autoimmune pancreatitis is uncommon in the Western world, particularly in Europe. We report the first case of a Caucasian male with typical features of autoimmune pancreatitis in the UK. Recognizing autoimmune pancreatitis as a new clinical entity in Europe will change the management of many patients who have been labelled as having acute or chronic pancreatitis.

Is Assessment of Popliteal Artery Diameter in Patients Undergoing Screening for Abdominal Aortic Aneurysms a Worthwhile Procedure

PURPOSE

The aim of this study was to assess whether screening of popliteal arteries in patients undergoing ultrasound screening of their abdominal aortas was worthwhile.

METHODS

All male patients undergoing ultrasound screening for abdominal aortic aneurysm (AAA) during the period February 2000 to June 2002 were offered scanning of their popliteal arteries. All scans were performed by a single, trained operator using a Sonosite 180.

RESULTS

Four hundred and forty-nine patients underwent screening and thus 898 popliteal arteries were assessed. The mean aortic diameter was 2.1 standard deviations (SD) 0.5 cm and the upper limit of normal (2 SD) was 2.7 cm. The mean diameter of the popliteal arteries was 0.74 SD 0.11 and the upper limit of normal was 0.96 cm. Thirty patients had aortic diameters greater than 2.5 cm (ectatic or aneurysmal aortas) but based on a popliteal diameter of 2 cm, no popliteal aneurysms were detected. However, 39 (4.3%) popliteal arteries measured > or = 1 cm (> mean+2 SD); 3/60 (5%) in the ectatic/AAA subgroup and 36/838 (4.3%) in the non-AAA subgroup.

CONCLUSIONS

This study has shown that, using conventional definitions, the imaging of popliteal arteries during screening for AAAs does not detect any popliteal aneurysms and is thus of limited value. However, if a definition of popliteal aneurysm of > or = 1 cm (based on mean+2 SD) is used then 39/898 (4.3%) of arteries would be regarded as having abnormal diameters and may require surveillance.

Registrar operating experience over a 15-year period: more, less or more or less the same?

BACKGROUND

Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years.

METHODS

A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded.

RESULTS

Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight.

CONCLUSION

SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained.

Giant mature cyst formation following mesh repair of hernias: An underreported complication?

BACKGROUND

Numerous complications have been described following the implantation of synthetic meshes during hernia repair; one of the rarest, with only three reported cases, is giant mature fibrous cyst formation. Our clinical experience with this complication has led us to believe that it may be more common than previously thought.

METHODS

Surgical operation notes and pathology archives were reviewed for the period January 1998-January 2002 to determine the prevalence of mature cyst formation following mesh repair of hernias.

RESULTS

Out of 1100 hernia repair operations involving the use of synthetic meshes in our institution during the period of study, five developed histologically confirmed mature fibrous cysts giving a prevalence of 0.45% for this complication.

CONCLUSION

The formation of a giant mature cyst following mesh repair of hernias is an underreported complication.

Transmission of donor melanoma to multiple organ transplant recipients

Malignant melanoma represents the most common tumour responsible for donor-derived post transplantation malignancies. We report the varied presentation and outcome of three graft recipients (two kidney and hepatic) who developed metastatic melanoma following cadaveric organ transplantation from a single multiorgan donor. Two of the recipients presented with symptomatic metastatic lesions and the third patient, despite being carefully monitored, developed evidence of metastatic cutaneous melanoma. Two of the patients died as a direct result of their melanomas. The recipients of corneal and cardiac grafts remain disease-free. We conclude that despite careful screening, donor-derived tumours remain a not uncommon clinical entity. The identification of a lesion in one recipient should prompt immediate examination and investigation of the remaining recipients of multiorgan donations.

Abdominal aortic aneurysm and its correlation to plasma homocysteine, and vitamins

BACKGROUND

Hyperhomocysteinemia is a recognised independent risk factor in the genesis of atherosclerotic diseases. However, very little is known about the relationship between homocysteine and abdominal aortic aneurysm (AAA). Vitamins, namely B12 and folic acid have been implicated in the regulation of plasma homocysteine levels. However, there has been no prospective study that has analysed the relationship of AAA and plasma homocysteine in light of serum vitamin levels.

AIMS

To study the relationship between plasma homocysteine, serum B12 and folic acid levels, and AAA.

METHOD

Case control study including 38 AAA patients and 36 controls. Fasting homocysteine, B12 and folic acid were determined in serum separated within 1 h of blood collection using a fluorescence polarisation immunoassay technique (FPIA).

RESULTS

Twenty-six (68%) of the AAA patients had elevated levels of homocysteine compared to 2 (6%) in the case control group. The mean homocysteine level in the AAA group was 19.4 micromol/L (SE +/- 1.1) (95% CI 17.17-21.65) and in the control group was 10.9 micromol/L (SE +/- 1) (95% CI 9.95-11.88) (p<0.001). Mean vitamin B12 levels in the AAA and the controls was 332.11 pg/L (SE +/- 16.44) and 414.33 pg/L (SE +/- 19.72), respectively (p<0.004). Mean folic acid in the AAA was 8.02 (SE +/- 0.71) and the control was 9.8 etagm/L (SE +/- 0.69), (ns).

CONCLUSION

This study confirms significantly higher levels of plasma homocysteine in AAA patients but lower levels of B12. Use of supplemental vitamins that should lower plasma homocysteine may modify vascular disease progression. Clinical trials in this direction are warranted.

Non-Arteritic Anterior Ischaemic Optic Neuropathy: A New Indication for Carotid Endarterectomy

We present a case of non-arteritic anterior ischaemic optic neuropathy (NAION) associated with ipsilateral internal carotid artery stenosis, in a patient who presented with sudden loss of vision. This patient underwent a carotid endarterectomy and reported both subjective and objective improvement in vision in the immediate postoperative period and a complete resolution of symptoms at 6 weeks follow-up. This case raises the question of a new indication for carotid endarter-ectomy in selected cases of NAION.

Prioritizing treatment in cases of concurrent abdominal aortic aneurysm

Patients with concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy present a clinical dilemma because of the difficulty in deciding which pathology to address first. As this scenario is not commonly encountered, clear guidelines are not available to help in the decision-making process. Surgery for malignancy has been said to increase the risk of postoperative aneurysm rupture, but simultaneous cancer surgery and primary repair of the aneurysm may carry the risk of prosthetic graft infection. This paper describes a further complication that may arise in the setting of concomitant intra-abdominal malignancy carcinoma and AAA, namely peripheral embolism.

Intestinal ischaemia

Over the past three decades major advances have been made in the diagnosis and management of mesenteric ischaemia. Early identification and treatment of this condition has reduced its mortality and morbidity. This review discusses the causes, preliminary and definitive investigations, and treatment protocols relating to gut ischaemia.

Issues of consent in renal transplantation

BACKGROUND

Renal transplantation is a semi-elective procedure. The specific risks of surgery are well-known. Obtaining informed consent is a complex process made more complicated in transplantation by the long-term nature of some of the risks involved.

METHODS

A questionnaire survey was conducted of consultant transplant surgeons to establish current practice regarding the levels of information and risks discussed as part of the consent process.

RESULTS

Responses were received from 47 (76%) of consultants. Risks were discussed by a range of individuals. Pre-assessment clinics were used by 70% of units to start the process. Only 74% routinely discussed malignancy and only 75% the risks of cytomegalovirus infection. Risks with individual organs were discussed by 32 (68%)--particularly HLA match, cold ischaemia, sensitisation, donor age and caused of donor death.

CONCLUSIONS

The current practice identified by this study falls broadly within General Medical Council guidelines on informed consent. There is wide variation in current practice which is highlighted and discussed in relation to case law and the levels of risk that a patient should expect to be informed of.