790 Upper Gastrointestinal (UGI) Mural Thickening on Computed Tomography (CT) and its Significance in The Multi-Disciplinary Team (MDT) Pathway

Aim

Patients are frequently referred to the UGI MDT based on CT reported thickening of either the oesophagus, stomach, or duodenum. We have sought to illustrate the efficacy of CT within the UGI cancer referral pathway.

Method

A retrospective analysis was carried out on patients referred to the UGI MDT at a University Teaching Hospital over a 22-month period. Patients referred with CT evidence of UGI tract thickening prior to endoscopy were included. CT findings were correlated with symptomatology, subsequent endoscopy, and histology findings.

Results

442 patients were referred to the UGI MDT between April 2014 and February 2016. 125 were referred for CT thickening alone (67 (53.2%) oesophageal, 49 (39.2%) gastric, 9 (7.2%) duodenal). 49 (39.2%) patients were subsequently diagnosed with UGI cancer, 57 (45.6%) had evidence of benign disease and 18 (14.4%) patients had no abnormality evident on endoscopy. CT thickening of 15mm and above was significantly more likely be malignant versus thickening less than 15mm [42/87 (48.3%) vs 7/38 (18.4%); p < 0.05]. Patients with thickening in the presence of a hiatus hernia were significantly less likely to have an associated cancer vs those without [3/26 (13%) vs 20/42 (51.1%); p < 0.05].

Conclusions

We conclude that patients should not be referred for MDT opinion on CT evidence of UGI thickening alone. All patients should have an endoscopy prior to referral, particularly those with a hiatal hernia on CT. A high index of suspicion for malignancy should be adopted in patients with thickening greater than 15mm on imaging.

559 One Mesenteric Defect, Two Segments of Colon, A Number of Surgical Strategies! A Rare Case of An Internal Hernia Causing Bowel Ischemia

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with signs and symptoms of an acute abdomen. Following surgical review, taking into consideration the patient’s clinical, biochemical, and radiological findings, the patient was taken for immediate emergency surgical exploration. A laparoscopic approach was initially taken, which revealed dilated and ischemic colon, and therefore an open approach was then adopted. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischemic. A number of surgical strategies were considered, and given the patients age it was decided to preserve as much normal bowel as possible. Thus, a right hemi- and sigmoid colectomy were performed with an ileo-transverse anastomosis and formation of an end colostomy. In this case, radiological diagnosis pointed to a suspicion of an internal hernia, and operative diagnosis highlighted a rare mesenteric defect causing herniation and subsequent ischemia. Relying on the patient’s clinical condition and an early decision for surgical intervention resulted in a positive outcome for outpatient. The patient made a good recovery following the bowel preserving surgery.

The effects of supervised exercise training 12-24 months after bariatric surgery on physical function and body composition: a randomised controlled trial

BACKGROUND

Bariatric surgery is effective for the treatment of stage II and III obesity and its related diseases, although increasing evidence is showing weight regain ~12-24 months postsurgery. Weight regain increases the risk of physical function decline, which negatively affects an individual's ability to undertake activities of daily living. The study assessed the effects of a 12-week supervised exercise intervention on physical function and body composition in patients between 12 and 24 months post bariatric surgery.

METHODS

Twenty-four inactive adult bariatric surgery patients whose body mass index remained ⩾30 kg m² 12 to 24 months post surgery were randomised to an exercise intervention (n=12) or control group (n=12). Supervised exercise consisted of three 60-min gym sessions per week of moderate intensity aerobic and resistance training for 12 weeks. Control participants received usual care. The incremental shuttle walk test (ISWT) was used to assess functional walking performance after the 12-week exercise intervention, and at 24 weeks follow-up. Measures of anthropometric, physical activity, cardiovascular and psychological outcomes were also examined. Using an intention-to-treat protocol, independent t-tests were used to compare outcome measures between groups.

RESULTS

Significant improvements in the exercise group were observed for the ISWT, body composition, physical function, cardiovascular and self-efficacy measures from baseline to 12 weeks. A large baseline to 12-week change was observed for the ISWT (exercise: 325.00±117.28 m; control: 355.00±80.62 m, P<0.001). The exercise group at 24 weeks recorded an overall mean improvement of 143.3±86.6 m and the control group recorded a reduction of -32.50±75.93 m. Findings show a 5.6 kg difference between groups in body mass change from baseline to 24 weeks favouring the exercise group.

CONCLUSIONS

A 12-week supervised exercise intervention led to significant improvements in body mass and functional walking ability post intervention, with further improvements at the 24-week follow-up.

Changes in physical activity behaviour and physical function after bariatric surgery: a systematic review and meta-analysis

Although physical activity performed after bariatric surgery is associated with enhanced weight loss outcomes, there is limited information on patients' physical activity behaviour in this context. This systematic review and meta-analysis assessed pre-operative to post-operative changes in physical activity and physical function outcomes among obese adults undergoing bariatric surgery. A total of 50 studies met inclusion criteria with 26 papers reporting data for meta-analysis. Increases in both objectively recorded and self-reported physical activity at 12 months were demonstrated. Studies indicated that there was a shift towards a greater amount of active time, but of a lower intensity within the first 6 months of bariatric surgery, suggested by a reduction in moderate to vigorous physical activity but an increase in step count. A standardized mean difference (SMD) of 1.53 (95% CI: 1.02-2.04) based on nine studies indicated improved walking performance at 12 months. Similarly, analysis of five studies demonstrated increased musculoskeletal function at 3-6 months (SMD: 1.51; 95% CI: 0.60-2.42). No relationship was identified between changes in weight and walking performance post-surgery. More studies assessing physical activity, physical function and weight loss would help understand the role of physical activity in optimizing post-operative weight and functional outcomes.

Patterns of success and failure with laparoscopic Toupet fundoplication

BACKGROUND

Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF).

METHODS

A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision.

RESULTS

At a mean follow-up of 30 months (range, 3-51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate.

CONCLUSION

Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.

Uncomplicated penetrating colonic injury

The case of a patient with an air gun pellet injury to the right colon is reported. This was treated conservatively, and the pellet was passed per rectum 12 hours after the injury. Gunshot wounds to the abdomen do not necessarily warrant immediate laparotomy. Sieving of bowel motions may identify if the foreign body has been passed.

Road humps: accident prevention or hazard?

Two cases of injury to passengers seated on public transport buses occurred after the vehicles had traversed road humps. While the potential dangers to seated bus passengers have been acknowledged in the Department of Transport literature, specific mention in medical reports is lacking. Should the United Kingdom follow the example set by the United States, where the placement of road humps on bus routes is avoided?