Proximal acid reflux treated by fundoplication predicts a good outcome for chronic cough attributable to gastro-oesophageal reflux disease.

PURPOSE: The aim for this study is to examine whether proximal, as opposed to distal, oesophageal reflux predicts a good outcome after fundoplication in patients with suspected acid-induced chronic cough. METHOD: Between 1999 and 2007, 81 patients with refractory chronic cough underwent manometry and dual-probe pH studies. In 59 patients, pathological reflux was confirmed, and 21 of these underwent laparoscopic fundoplication by a single surgeon. Proximal reflux was defined as an upper channel time pH <4 of >1.4%. The Chi-square test and Mann-Whitney U test were used in the statistical analysis. RESULTS: All patients with heartburn had their symptoms abolished by surgery. The proximal extent of reflux predicted cough improvement. Eleven of 14 patients with proven proximal reflux had complete symptom relief from surgery as opposed to two of seven with distal only reflux (Chi-square = 4.95; degrees of freedom = 1; p = 0.026). There was no correlation between oesophageal motility (as assessed by per cent abnormal wet swallows) and pathological reflux on outcome of surgery. Correlation of episodes of coughing with episodes of proximal or distal reflux was poor and had no useful predictive value. CONCLUSION: Patients with refractory chronic cough are significantly more likely to benefit from surgery if their pH study shows an upper channel pH time >1%.

Safe transition from open to laparoscopic fundoplication by an established consultant--the importance of repeated audit.

BACKGROUND: Serious complications of laparoscopic fundoplication (LF) have been reported by surgeons new to LF. We investigated whether the reported benefits of LF could be realised by an established consultant, new to LF, without compromising safety, control of reflux or dysphagia rates obtained after open surgery. PATIENTS AND METHODS: Outcome of 65 consecutive open fundoplications was audited. After training in LF, this audit was compared with an identical prospective audit of 65 patients undergoing LF. RESULTS: No significant differences occurred between the two groups in relief of reflux. LF resulted in: (i) shorter postoperative stay (median 2 days versus 7 days, P < 0.001); (ii) earlier return to work (median 4 weeks versus 9 weeks, P < 0.001); (iii) shorter duration of postoperative dysphagia (median 4 weeks versus 9 weeks, P = 0.01); and (iv) less intra/postoperative complications (7.7% versus 32.3%, P < 0.001). CONCLUSIONS: LF can be introduced safely by established consultants provided that adequacy of training is confirmed by repeated audit.

Gastroaortic fistula as an early complication of esophagectomy.

Gastroaortic fistula following esophagogastrectomy is an uncommon and invariably fatal complication without urgent surgical intervention. We report 1 such case and review the world literature identifying 22 previous cases. It characteristically presents 2 to 3 weeks after esophagogastrectomy with an initial herald bleed, followed by a latent period with a mean duration of 10 hours (range: 30 minutes to 3 days) and final exsanguination. Only 1 patient in this series survived. Awareness is necessary to allow prompt diagnosis and treatment of this almost invariably lethal but curable condition.

Testicular torsion: most delay occurs outside hospital.

Testicular torsion leading to orchidectomy is a major catastrophe for the patient and continues to occur. We studied the causes of delay leading to orchidectomy by conducting a retrospective hospital-based audit of all patients undergoing scrotal exploration for suspected testicular torsion over a 2 year period. Fifty patients underwent surgery of whom 22 (44%) had testicular torsion and six required orchidectomy. All patients with a dead testicle presented more than 6 h after onset of symptoms. Of those presenting with 6, 24 or more than 24 h of symptoms, salvageable testes were found in 100%, 83% and 75%, respectively. The median duration of symptoms in patients with viable twisted testicle was 5.5 h compared with 42 h in those who underwent orchidectomy. Late presentation to hospital was the major cause of delay leading to orchidectomy in patients with testicular torsion. Greater effort in health education and direct or self-referral to hospital may reduce this delay.

Mucosal pharmacokinetics and pilot study of short course of parenteral imipenem in the eradication of Helicobacter pylori.

Eradication of Helicobacter pylori infection is known to reduce the incidence of duodenal ulcer recurrence. The most commonly used regimen for H. pylori infection is triple antimicrobial therapy for 1-2 weeks. This treatment is associated with frequent side effects and hence unsatisfactory compliance. As in vitro data showed that H. pylori is sensitive to imipenem, the pharmacokinetics of this drug in the gastric milieu, and the clinical efficacy of imipenem with omeprazole in eradicating H. pylori infection were studied. Imipenem/cilastatin levels in serum, gastric secretion and gastric mucosa were assayed in four patients after intravenous injection of a bolus dose of 500 mg. The serum and gastric secretion levels of imipenem achieved were more than 10 times the minimum inhibitory concentration of the drug for H. pylori. Gastric mucosal levels of imipenem vary considerably with time, which probably indicates rapid elimination of the drug into the gastric lumen. In the second part of this study, imipenem/cilastatin was given intravenously for the first 2 days after diagnosis of H. pylori infection in patients with endoscopically confirmed duodenal ulcers. The patients were also treated with 4 weeks of omeprazole. Clearance of H. pylori was initially achieved at the end of 2 days in 20 out of 22 (91%) patients. However, when the biopsies were repeated at 8 weeks, recurrence of H. pylori infection was evident in 19 cases (86.3%) indicating a failure of eradication. It was concluded that imipenem/cilastatin in combination with omeprazole failed to eradicate H. pylori infection.

Graded exercises for basic training in laparoscopic surgery.

A series of graded exercises for use in laparoscopic simulation is described. These exercises are designed to introduce the basic skills required for laparoscopic surgery, and have been found to be useful both for the training of junior surgeons and in workshops.

Duodenal ulcer healing by eradication of Helicobacter pylori without anti-acid treatment: randomised controlled trial.

Randomised trials have shown that duodenal ulcers treated by H2 blockers heal faster if Helicobacter pylori is eradicated concurrently. It remains unknown whether eradication of H pylori without suppression of acid-secretion, is sufficient to allow healing. 153 patients with H pylori infection and duodenal ulcer were randomised to receive either a 1-week course of bismuth subcitrate, tetracycline, and metronidazole (76), or omeprazole for 4 weeks with the same three-drug regimen for the first week (77). Endoscopy and antral biopsies were done at entry and 4 weeks after treatment. 132 patients were suitable for analysis. Duodenal ulcers healed in 60 (92%; 95% CI 86-100%) patients taking bismuth, tetracycline, and metronidazole compared with 63 (95%; 88-100%) taking omeprazole in addition to the three other drugs. H pylori was eradicated in 61 (94%; 88-100%) who received only three drugs compared with 66 (98%; 96-100%) who received omeprazole as well. Symptoms were reduced more effectively during the first week in patients who received omeprazole (p = 0.003). We conclude that a 1-week regimen of bismuth, tetracycline, and metronidazole for patients with H pylori and duodenal ulcer eradicates the organism and heals the ulcer in most patients. Concurrent administration of omeprazole reduces ulcer pain more rapidly but has no effect on ulcer healing.

One-year follow-up of duodenal ulcers after 1-wk triple therapy for Helicobacter pylori.

OBJECTIVE: to study the ulcer recurrence rate of Helicobacter pylori-positive duodenal ulcers at 1 yr after eradication of the bacteria by triple therapy. METHOD: Patients with H. pylori-positive duodenal ulcers were randomized to receive either triple therapy for 1 wk plus omeprazole for 4 wk (Triple+OMP) (n = 78), or omeprazole alone (OMP) for 4 wk (N = 77). Patients were followed up every 3 months for symptom enquiry. At 1 yr, all asymptomatic patients were invited to attend for gastroscopy. RESULTS: At 8 wk, 16 patients in the OMP group and four in the Triple+OMP group had an ulcer. During the 1-yr period, 12 patients in the OMP group and no patient in the Triple+OMP group developed symptomatic ulcers. At follow-up endoscopy at 1 yr, another 10 ulcers were detected in the OMP group and two in the Triple+OMP group. Fifteen patients in the OMP group and 13 in the Triple+OMP group were lost to follow-up. In total, ulcers were detected in 39 of 61 (64%) assessable patients in the OMP group, and in six of 65 (9%) assessable patients in the Triple+OMP group after 1 yr (chi 2 test: p < 0.001). Of the patients whose H. pylori were successfully eradicated by Triple+OMP at 8 wk, 90% remained H. pylori negative at 1 yr. CONCLUSION: Triple therapy for 1 wk eradicates H. pylori infection and significantly reduces duodenal ulcer relapses.

Surgery for parathyroid adenoma and hyperplasia: relationship of histology to outcome.

Recent histopathologic evidence challenges the teaching that enlargement of a solitary parathyroid gland is invariably caused by an adenoma, whereas multiple gland enlargement results from hyperplasia. We have re-examined the parathyroid tissue obtained from 152 consecutive patients undergoing surgery for primary hyperparathyroidism and compared it with their clinical outcome. Our approach was to excise enlarged glands and biopsy the remainder. In 124 patients (82%) at least three glands were biopsied or removed. The ratio of adenoma to hyperplasia was reversed by our histologic re-examination; adenomas were found in only 27 patients (25 single, two double), whereas hyperplasia was found in 117 patients (one gland, 87 patients; two glands, 16 patients; three glands, five patients; four glands, nine patients). Normal tissue only was reported in eight patients. During a 2-year follow-up, five patients (3%) developed hypocalcemia and none developed recurrent hypercalcemia. Our results indicate that a full neck exploration with removal of all enlarged glands is more important than the histologic diagnosis in planning a successful surgical strategy for primary hyperparathyroidism.

Randomised controlled trial of short term treatment to eradicate Helicobacter pylori in patients with duodenal ulcer.

OBJECTIVE: To determine whether one week's drug treatment is sufficient to eradicate Helicobacter pylori in patients with duodenal ulcer. DESIGN: Single blind, randomised controlled trial. SETTING: Specialised ulcer clinic in a teaching hospital. PATIENTS: 155 patients with H pylori and a duodenal ulcer verified endoscopically which had either bled within the previous 24 hours or was causing dyspepsia. INTERVENTIONS: Patients were allocated randomly to receive either omeprazole for four weeks plus bismuth 120 mg, tetracycline 500 mg, and metronidazole 400 mg (all four times a day) for the first week (n = 78), or omeprazole alone for four weeks (n = 77). Further endoscopy was performed four weeks after cessation of all drugs. MAIN OUTCOME MEASURES: Presence or absence of H pylori (by urease testing, microscopy, and culture of antral biopsy specimens), duodenal ulcer, and side effects. RESULTS: Eradication of H pylori occurred in 70 (95%) patients taking the four drugs (95% confidence interval 86% to 97%) compared with three (4%) patients taking omeprazole alone (1% to 11%). Duodenal ulcers were found in four (5%) patients taking the four drugs (2% to 12%) and in 16 (22%) patients taking omeprazole alone (14% to 32%). Mild dizziness was the only reported side effect (six patients in each group) and did not affect compliance. CONCLUSIONS: A one week regimen of bismuth, tetracycline, and metronidazole is safe and effective in eradicating H pylori and reduces the number of duodenal ulcers four weeks after completing treatment.

Safety and feasibility of percutaneous ultrasound guided puncture of the gall-bladder for crystal analysis.

The safety and feasibility of ultrasound guided percutaneous aspiration (USPA) of bile, for bile crystal analysis was assessed critically. Forty-four patients about to undergo elective cholecystectomy underwent intended transhepatic USPA 1 h before their operation. At laparotomy a careful inspection for bile and blood leakage was made and a further sample of gall-bladder bile collected. Successful USPA occurred in 40 of the 44 patients. The four unsuccessful cases each had a gall-bladder packed with stones and contained virtually no bile. Three patients developed bile leak after transperitoneal (n = 2) and transhepatic (n = 1) puncture of the gall-bladder and another patient lost 100 mL of blood. Microscopic analysis of paired bile samples confirmed that gall-bladder bile (as opposed to hepatic bile) had always been aspirated. Ultrasound guided percutaneous aspiration of bile offers a simple and promising alternative to duodenal intubation, but considerable experience is required before it can be recommended as its replacement.

Prophylactic sclerotherapy for esophageal varices: long-term results of a single-center trial.

Survival after prophylactic sclerotherapy was assessed in a single-center study involving 99 cirrhotic (41 alcoholic) patients enrolled over 8-yr. The wedged hepatic vein pressure gradient was measured; those with pressure greater than or equal to 12 mm Hg were randomized to receive sclerotherapy or no treatment. The rest were not randomized. Patients in all three groups who bled were treated with emergency endoscopy and sclerotherapy. Stratification according to presence of ascites was also undertaken. Median follow-up was 61 mo (range = 14 to 107 mo). Survival among unrandomized patients was significantly longer than among randomized patients (p less than 0.006), but there was no significant difference between those treated by sclerotherapy and the controls (p = 0.27). Alcoholic cirrhotic patients undergoing sclerotherapy had better 2-yr survival than did the controls (80% vs. 43%; p = 0.09), but this benefit was not sustained at 5 yr. Survival in the nonalcoholic patient groups was identical. Only 10 of 50 deaths were caused by variceal bleeding. Forty-eight percent of patients with large varices bled, compared with 20% of patients with small varices. Wedged hepatic vein pressure less than 12 mm Hg accurately identified alcoholic patients at low risk of variceal bleeding but not nonalcoholic patients. Only four episodes of variceal bleeding were attributable to elective sclerotherapy. We conclude that in our population, prophylactic sclerotherapy alone does not improve survival. The discrepancy in survival between alcoholic and nonalcoholic cirrhotic patients suggests that factors other than variceal hemorrhage may be responsible for the difference.

Breast within a breast: a review of breast hamartomas.

A 22-year-old woman who presented with a large lump in the left breast, subsequently found to be a breast hamartoma, is described. A full review is given of this rare and unusual benign breast lesion, which is likely to be recognised increasingly with the advent of mammographic screening.

Malignant haemangiopericytoma of the pelvic retroperitoneum.

A case of malignant haemangiopericytoma of the pelvic retroperitoneum is described. The patient finally died of the complications of radiotherapy. In the absence of any reported long term benefits of adjuvant radiotherapy to the lesion, the lower morbidity of chemotherapy may make this form of adjuvant therapy worthy of further evaluation.

Anorectal varices, haemorrhoids, and portal hypertension.

In a prospective study of 100 consecutive patients with cirrhosis, 44% had anorectal varices. The prevalence of anorectal varices rose with progression of portal hypertension; it was 19% in cirrhotic patients without portal hypertension compared with 59% in those who had bled from oesophageal varices. There was no evidence that endoscopic sclerotherapy directly increased the prevalence of anorectal varices. Haemorrhoids occurred independently of anorectal varices and their presence was unrelated to the degree of portal hypertension. These data provide further evidence that haemorrhoids and anorectal varices are separate and distinct entities. However, both can bleed and careful examination is essential to prevent misdiagnosis and inappropriate treatment.