High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data. OBJECTIVES: To objectively and more accurately assess the impact of SG on esophago-gastric physiology. SETTING: Centre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia. METHODS: Prospective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG. RESULTS: There were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5-29.6 mm Hg) and failed swallows (3.1-7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%-7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3-4.7) and weak acid reflux episodes were significantly increased (15.4-55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%-6.7%), as did DeMeester scores (5.8-24.5) and the numbers of long reflux episodes (.1-4.4) and weakly acidic episodes (22.1-89.2). CONCLUSION: SG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.

Diagnosis of acute appendicitis and clinical outcomes following laparoscopic surgery: a cohort study.

BACKGROUND: The clinical assessment of appendicitis remains challenging, especially between genders and across age groups. Negative appendicectomy rates (NARs) can be as high as 43% and are significantly higher in the female population. Evidence suggests blood markers such as white blood cell count (WBC) and C-reactive protein have poor predictive value. There is a lack of regional data assessing workup and outcomes following laparoscopic appendicectomy. METHOD: A multi-centre, retrospective study was performed. A database of adult patients undergoing laparoscopic appendicectomy at Manly and Mona Vale Hospitals (Sydney, Australia) was analysed with regard to clinical assessment and outcomes. The primary endpoint was histological confirmation of acute appendicitis (AA). Secondary endpoints were length of hospital stay, NAR, correlation between preoperative WBC and AA, and sensitivity of preoperative imaging. RESULTS: A total of 501 patients were included in the study. AA was confirmed in 91.2% of patients. The NAR was 8.8% across all subgroups. The NAR was 12.1% in women. 95.6% of patients had preoperative imaging. There was a statistically significant relationship between WBC and length of stay (P < 0.005), with elevated WBC correlating with increasing length of stay. CONCLUSION: We concluded that preoperative WBC when elevated can be used as a marker for AA and also as a predictor for length of stay in hospital. We would also advocate the use of preoperative imaging in young women and children.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: long-term results at St George Hospital, Australia.

BACKGROUND: Peritoneal carcinomatosis (PC) results from the secondary spread of many intraabdominal tumour types, such as colorectal malignancy (colorectal cancer, CRC), disseminated peritoneal adenomucinosis (DPAM), appendiceal cancer, ovarian carcinoma, sarcoma or from the occurrence of primary peritoneal disease such as peritoneal mesothelioma. The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has seen improvements in survival in selected cases of these cancers. METHODS: Between 1996 and 2014, a prospective database of 675 patients was created for the peritonectomy unit at our hospital. In total, 827 peritonectomy procedures (including redo CRS) were performed for the major subgroups of PC: DPAM 220; appendiceal cancer (peritoneal mucinous adenocarcinoma (PMCA)) 191; CRC 234; diffuse malignant peritoneal mesothelioma (DMPM) 73 and others 109. There were 152 redo-peritonectomy procedures within the total mentioned earlier (CRC 26; DPAM 58; DMPM 18; appendix 40; other 10). RESULTS: The 5-year survivals for DPAM and PMCA were 80% and 42% respectively. The 5-year survivals for appendiceal cancer with peritoneal cancer index (PCI) <10, 10-20 and >20 were 60, 57 and 37% respectively (P = 0.09). The 2- and 5-year survivals for CRC were 56 and 24% respectively. The 5-year survivals for PCI 0-5, 6-10, 11-15 and >15 were 59, 15, 7 and 0% respectively (P = 0.000). The 5-year survival for DMPM with PCI < 10, 10-20 and >20 were 100, 55 and 39% respectively (P = 0.01). CONCLUSION: CRS in combination with HIPEC provides a chance of long-term survival in selected cases of PC when compared with systemic therapy alone.

Differential muscarinic receptor gene expression levels in the ventral medulla of spontaneously hypertensive and Wistar-Kyoto rats: role in sympathetic baroreflex function.

OBJECTIVE: We demonstrated previously that central muscarinic cholinergic receptor (mAChR) activation increased splanchnic sympathetic nerve activity and sympathetic baroreflex function via activation of mAChR in the rostral ventrolateral medulla (RVLM), and we found that some RVLM bulbospinal neurons contain muscarinic M2R mRNA. Here, we examined the gene expression, cellular distribution and functional role of muscarinic receptors in the RVLM in spontaneously hypertensive rats (SHR) compared with Wistar-Kyoto (WKY) rats. METHOD AND RESULTS: Using the sensitive technique of quantitative real time reverse transcriptase-PCR, M2R mRNA level was elevated two-fold (P<0.05) and M4R mRNA was downregulated two-fold (P<0.001), with all other receptors expressed at similar levels, in the rostral ventral medulla of SHR compared with WKY. Bulbospinal, but not catecholaminergic neurons, in the RVLM expressed M2R mRNA (M2RR), and similar numbers were found in the RVLM of SHR and WKY. Could elevated M2R within individual neurons or enhanced presynaptic activity reflects enhanced cholinergic effects in the RVLM? Activation of central mAChR using oxotremorine evoked a larger increase in mean arterial pressure in SHR compared with WKY (P<0.01); however, oxotremorine-induced increases in splanchnic sympathetic nerve activity, and sympathetic baroreflex function were similar in SHR and WKY. CONCLUSION: These data indicate that enhanced pressor responses in SHR, following centrally mediated mAChR activation, are not associated with RVLM-mediated constriction of the splanchnic circulation or effects on the sympathetic baroreflex, but could reflect modified mAChR gene expression elsewhere. RVLM-dependent splanchnic sympathetic nerve activity effects, evoked by mAChR activation, are not mediated by the differential M2/M4 receptor mRNA levels identified in SHR compared with WKY.