Distal antral gastropexy - a novel technique to prevent recurrence of giant hiatus hernia in selected cases - a cohort study.

INTRODUCTION: The recurrence rate of giant hiatus hernias (GHH) following repair is high (30%) and increases with the hernia size and previous revision surgery. The mechanism of recurrence is poorly understood. METHODS: This is a retrospective cohort study of all consecutive patients who underwent repair of giant hiatus hernia in a tertiary upper GI referral centre from November 2000 to November 2014. Patients who underwent redo surgery were identified and data on intra-operative findings and procedure performed at primary and redo surgery from their operation notes were collected. RESULTS: A total of 81 patients underwent primary repair of GHH over the 14 year study period. 10 (12.3%) had symptomatic/radiological recurrence of which 4 were found to have the distal stomach herniating into the chest despite having an intact intra-abdominal wrap/gastropexy. To prevent migration of the distal stomach into the chest, distal gastropexy - fixing the antrum to the anterior abdominal wall, was added to 'conventional' gastropexy in 5 subsequent cases, in whom the antrum was in the chest preoperatively. These cases have no evidence of recurrence at the end of 6 months follow up. CONCLUSION: Securing the antrum of stomach to the anterior abdominal wall may prevent migration of the distal stomach and other infracolic organs into the chest and thus reduce recurrence of some GHH where antrum had been in chest previously.

Is C-reactive protein a useful adjunct in selecting patients for emergency cholecystectomy by predicting severe/gangrenous cholecystitis?

UNLABELLED: Gangrenous cholecystitis is difficult to diagnose clinically and carries risk of morbidity and mortality if not treated urgently. Complex scoring systems exist to predict the condition. C reactive protein may be a single independent predictor as suggested in this small study. BACKGROUND: Gangrenous cholecystitis (GC) is a serious sequel of acute cholecystitis occurring in 2-30% patients and has a mortality of 0.2-0.5%. Urgent surgical intervention is important to reduce morbidity and mortality therefore it is important to identify patients with GC from non-severe cholecystitis. The aim of this study is to determine biochemical and radiological markers, which is associated with the development GC and the value of C-reactive protein (CRP) at different cut-offs in predicting GC. METHODS: This is an observational cohort study of all consecutive patients who presented with biliary symptoms to the emergency department in a large NHS Hospital in the UK, from January to December 2012. They had cholecystectomies performed either during index admission or electively at later date by a team of 4 upper gastrointestinal surgeons. The gangrenous nature of the gallbladder was determined by operative findings and/or histopathology results. Parameters including age, gender, albumin, jaundice, gallbladder wall thickness on ultrasound scan, highest preoperative white blood count (WBC) and CRP value, were examined for their predictive value. RESULTS: 141 patients presented with acute biliary problems. 22 underwent emergency cholecystectomy and 119 were discharged and called back for elective surgery. Of these, 16 were gangrenous (11%). Patients with GC were significantly older (p = 0.016), had significantly higher CRP (p < 0.001) and WBC (p = 0.001), significantly lower albumin levels (p < 0.001) and higher percentage with thick walled gallbladder (p < 0.001). We found that a CRP value of more than 200 mg/dL has a 50% positive predictive value and 100% negative predictive value in predicting gangrenous cholecystitis with 100% sensitivity and 87.9% specificity. CONCLUSIONS: In this study CRP on its own has been shown to have high predictive value in predicting GC, but larger studies are needed to validate this finding. Monitoring trend of CRP in patients with acute cholecystitis may help early diagnosis and decision for early surgical intervention.

Can low dose spinal anesthesia combined with ultrasound guided bilateral ilioinguinal-iliohypogastric nerve blocks avoid use of additional epidural catheter in high risk obstetric cases? Our experience from two cases.

Critical obstetric cases associated with cardiac pathology may pose real challenge for anaesthesiologist during Caesarean section. Meticulous perioperative care and suitable selection of anaesthesia technique are the key to successful outcome. Single shot spinal anaesthesia is not used any more because of serious haemodynamic consequence. Progressive and controlled epidural local anaesthetic injection is mostly used in such cases. But recently combined spinal epidural anaesthesia and continuous spinal anaesthesia are suggested due to better precise control of haemodynamics and quicker onset. However, institution of such complex technique may require time which may not be feasible in emergency situations. Use of bilateral ilioinguinal-iliohypogastric nerve block along with low dose spinal anaesthesia may obviate the need of additional epidural catheter in such complicated cases. We hereby present our experience from two cases.

Advantages of intra-capsular micro-enucleation of schwannoma arising from extremities.

BACKGROUND: Schwannoma is the most common tumor of the peripheral nerves, with surgical enucleation being the established treatment modality. However, some schwannomas cannot be easily enucleated and this sometimes results in iatrogenic nerve injury even with atraumatic procedures. Here we present a retrospective review of the management of schwannoma in the extremities and compare clinical outcomes from the two techniques of extra-capsular and intra-capsular enucleation. METHODS: We reviewed 36 schwannomas from 35 patients who underwent surgical excision of schwannomas arising from the extremities. Twenty had undergone extra-capsular resection and 16 had undergone enucleation using the intra-capsular technique. The post-operative neurological deficits were graded as minor, major, and transient. The duration of symptoms, maximum tumor diameter and site of occurrence were compared between patients with the three grades of deficit. RESULTS: In total, 22 patients developed no sensory changes following enucleation of schwannoma or only temporary and minor changes that had fully resolved within 6 months. Ten patients developed new neurological deficits following surgery that took longer than 6 months to resolve. Four patients experienced new motor deficits or paresthesia following operation that had still not recovered at the final follow-up, all of whom underwent enucleation using the extra-capsular technique. Neurological deficit after enucleation was significantly lower using the intra-capsular compared with the extra-capsular technique. Patient age, duration of symptoms, maximum diameter of the tumor and site of occurrence did not influence the neurological deficit following enucleation of schwannoma. CONCLUSION: These results support intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection. Thorough pre-operative counseling of patients to inform them of the potential occurrence of neurological deficit is important.

Hodgkin's disease of appendix: report of a case.

BACKGROUND: A number of cases of non Hodgkin's lymphoma of the appendix have been described, but Hodgkin's lymphoma is extremely rare. To our knowledge there are only two reports up to 1966 and none since then. METHOD: We report a case of a 65-year-old gentleman who was treated for suspected Crohn's disease. He failed to respond to medical treatment and underwent right haemicolectomy. The resected segment of bowel demonstrated classical Hodgkin's disease originating in the appendix. He recovered well from the operation and responded well to postoperative chemotherapy. CONCLUSION: Hodgkin's lymphoma of appendix is extremely rare. This case demonstrates the significance of repeated clinical evaluation of patients particularly in the absence of expected response to therapy.

A review of the management of gallstone disease and its complications in pregnancy.

BACKGROUND: Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women. There have been significant developments in the management of gallstone disease, but risk to the fetus has prevented their routine application in pregnant women. We reviewed the literature to find the current best evidence for the management of gallstones and its complications in pregnancy. DATA SOURCES: MEDLINE and PubMed literature searches were performed to identify original studies. RESULTS AND CONCLUSIONS: Six studies comparing conservative with surgical management of cholecystitis showed no significant difference in incidence of preterm delivery (3.5% vs 6.0%, P = .33) or fetal mortality (2.2% vs 1.2%, P = .57). There was no maternal or fetal mortality in 20 reports of laparoscopic cholecystectomy and 9 reports of endoscopic retrograde cholangiopancreatography, thus indicating their safety when performed with necessary precautions. Laparoscopic cholecystectomy is a safe procedure in all trimesters. In 12 reports of gallstone pancreatitis, fetal mortality was 8.0% versus 2.6% (P = .28) in conservative and surgical groups, respectively, suggesting the need for earlier surgical intervention.

Combined endoscopic and laparoscopic approach for palliative resection of metastatic melanoma of the stomach.

BACKGROUND: Metastatic tumours of the stomach present a clinical dilemma for the surgeon. Palliative surgical resection can alleviate symptoms and prolong survival in selected patients. However, previous studies have used open methods of surgical resection with potentially high morbidity and mortality. We describe the use of laparoscopic wedge resection of the stomach for palliative resection of metastatic melanoma to highlight the benefits of this technique. CASE PRESENTATION: A 58 year old male was investigated for iron deficiency anaemia while under treatment for pulmonary metastatic malignant melanoma. An upper gastrointestinal endoscopy revealed a 5 cm diameter ulcer on the anterior wall of the stomach, biopsies from the ulcer confirmed metastatic melanoma. Laparoscopic wedge resection of the stomach lesion was performed without complication. CONCLUSION: Laparoscopic approach has many benefits and is useful for the palliative resection of rare tumours of the stomach in order to preserve the quality of life. Its use should be considered in selected patients.

D2 gastrectomy -- a safe operation in experienced hands.

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.

Feeding jejunostomy: is there enough evidence to justify its routine use?

BACKGROUND AND AIM: Intraoperative placement of feeding jejunostomy is a well-established method of providing access to enteral feeding. However, some studies describe serious complications related to this procedure. A retrospective study was undertaken to look at the technical complications related to the procedure. PATIENTS AND METHODS: Patients undergoing feeding jejunostomy in the thoracic and upper gastrointestinal surgical units at the Royal Victoria Hospital between January 1998 and December 1998 were included in the study. The charts of all the patients were studied retrospectively. RESULTS: Forty-two patients underwent a feeding jejunostomy in the time period studied. Thirty-one patients had a jejunostomy as an adjunct to major oesophageal or gastric surgery. In 5 patients, feeding jejunostomy was performed in conjunction with other palliative procedures and in 6 patients, it was performed as a sole procedure. Nine (21.4%) patients had procedure-related complications. Of these, 7 (16.7%) were minor including dislodgment of the tube (n = 4), blocked tube (n = 2), and intraoperative catheter damage (n = 1). Two (4.7%) patients had major complications requiring emergency laparotomy. One of these patients died as a result of a procedure- related complication. CONCLUSION: Feeding jejunostomy is associated with high morbidity and mortality. Its routine use may not be justified in the absence of evidence to support its use.

The influence of a hexametaphosphate-containing chewing gum on the wetting ability of salivary conditioning films in vitro and in vivo.

OBJECTIVE: Adsorbed conditioning films of salivary components on dental enamel surfaces or pellicles form the interface between teeth and the oral environment. The wetting ability of salivary conditioning films dictates biological adhesion phenomena such as plaque formation, calcification and staining, and also influences mouth perception through effects on lubricity. This study assessed the effects of hexametaphosphate release from a chewing gum matrix on the wetting ability of salivary conditioning films in vitro and in vivo. METHODOLOGY: Results obtained for hexametaphosphate chewing gum were compared with those produced by hexametaphosphate-containing dentifrice, which has been clinically proven to have efficacy for stain removal and prevention and dental calculus prevention. RESULTS: Contact angle assessments revealed that hexametaphosphate dentifrice produced markedly hydrophilic conditioning films in vitro. Hexametaphosphate chewing gums had only minor effects on surface contact angles in vitro. However, in vivo intra-oral contact angle measurements on tooth surfaces in volunteers showed that both hexametaphosphate dentifrice and chewing gum produced more hydrophilic tooth surfaces. CONCLUSION: These results support the activity of hexametaphosphate on tooth surfaces delivered both from dentifrice and chewing gum forms.

Unusual complications of ballooned feeding tubes.

Percutaneous Endoscopic Gastrostomy (PEG) and Feeding Jejunostomy (FJ) with a Foley catheter are well-established techniques for providing long-term nutritional support. Mechanical complications of these procedures are well recognised. We report two unusual complications of feeding tubes related to the balloon. Patient 1: A 23 years old female cerebral palsy patient had a PEG tube changed to a ballooned gastrostomy tube. Following this she developed abdominal cramps, vomiting and later on haematemesis. Contrast study showed migration of the balloon causing pyloric obstruction and a small prepyloric ulcer. Partially deflating the balloon and pulling it back to the original position corrected this. Patient 2: A 39 years old male cerebral palsy patient with a Foley catheter feeding jejunostomy developed obstructive symptoms within 48 hours of surgery. The balloon was deflated repeatedly without resolution. The catheter was impossible to withdraw and irrigate. Contrast instilled via the balloon channel demonstrated that the catheter was significantly stretched and the balloon was in terminal ileum. The balloon was fully deflated and easily withdrawn to be replaced with uninflated Foley catheter. Enteral feeding was easily reestablished. If a patient with a ballooned feeding tube develops intestinal symptoms balloon complications should be suspected. Contrast study through the feeding channel or balloon inflation channel is useful in diagnosing tube related complication. The threshold for imaging should be low, particularly in patients who are difficult to assess clinically.

Seat-belt syndrome revisited.

This report describes a complex syndrome of injuries occurring in a young female who was a back seat passenger wearing a lap-belt restraint in a high-speed road traffic accident. As a consequence of the forced flexion distraction injury of her lumbar spine, she sustained a fracture-subluxation of the first lumbar vertebra in association with a jejunal perforation and extensive small intestinal mesenteric laceration. She also had a large traumatic hernia of the anterior abdominal wall, which was overlooked at primary laparotomy. This report highlights collectively the classical combination of injuries associated with the lap-belt syndrome and demonstrates the importance of carefully inspecting the anterior abdominal wall for deficiencies, because traumatic herniation may be easily overlooked.

Phylogenetic Analysis of Bradyrhizobium japonicum and Photosynthetic Stem-Nodulating Bacteria from Aeschynomene Species Grown in Separated Geographical Regions.

Nearly complete and short partial 16S rRNA sequences were derived from PCR-amplified ribosomal DNAs of Bradyrhizobium japonicum USDA 136 and USDA 110 and five strains of bacteriochlorophyll-synthesizing bacteria isolated from stem nodules of Aeschynomene indica and other Aeschynomene species growing in different geographic regions, including India, The Philippines and North America. We confirmed that the five stem-nodulating strains examined synthesize bacteriochlorophyll a, and the absorption spectra of methanol-extracted cells contained a major absorbance peak at 770 nm. Strains isolated on different continents and from different Aeschynomene species were found to be phylogenetically homogeneous and exhibited levels of sequence similarity of more than 99%. The bacteriochlorophyll-synthesizing rhizobia, Bradyrhizobium japonicum, Blastobacter denitrificans, Afipia felis, and Rhodopseudomonas palustris exhibited levels of sequence similarity of 97% or greater and belong to a distinct line of descent within the alpha-2 subdivision of the Proteobacteria. Variable regions between positions 995 and 1045 provide potential target sites for design of a probe that is able to distinguish the photosynthetic rhizobia from closely related taxa.