Gastroesophageal signet ring cell carcinoma morbidity and mortality: A retrospective review.

BACKGROUND: Upper gastrointestinal (GI) signet ring cell carcinomas (SRCC) confer a poor prognosis. The benefit of operative intervention for this patient group is controversial in terms of overall survival. AIM: To investigate factors relating to survival in patients with upper GI SRCC. METHODS: A retrospective, tertiary, single-centre review of patients who were diagnosed with oesophageal, gastroesophageal junction and gastric SRCC was performed. The primary outcome was to compare mortality of patients who underwent operative management with those who had nonoperative management. Secondary outcomes included assessing the relationship between demographic and histopathological factors, and survival. RESULTS: One hundred and thirty-one patients were included. The one-year survival for the operative group was 81% and for the nonoperative group was 19.1%. The five-year survival in the operative group was 28.6% vs 1.5% in the nonoperative group. The difference in overall survival between groups was statistically significant (HR 0.19, 95%CI (0.13-0.30), P < 0.001). There was no difference in survival when adjusting for age, smoking status or gender. On multivariate analysis, patients who underwent surgical management, those with a lower stage of disease, and those with a lower Charlson Comorbidity Index (CCI) had significantly improved survival. CONCLUSION: Well-selected patients with upper GI SRCC appear to have reasonable medium-term survival following surgery. Offering surgery to a carefully selected patient group may improve the outcome for this disease.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series.

BACKGROUND: Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure. OBJECTIVES: To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes. SETTING: Three hospitals in Australia with both private and public (government funded) patients. METHODS: We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications. RESULTS: We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience. CONCLUSION: In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987-2020).

Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of 1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987-2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17-29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in BRCA1 and BRCA2 but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14-27% entered various lifestyle studies. From 1992-2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013-2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.

Improving Access to Bariatric Surgery for Rural and Remote Patients: Experiences from a State-Wide Bariatric Telehealth Service in Australia.

BACKGROUND: The state of Queensland, Australia, is large (1.85 million km2). The provision of bariatric care across the state is difficult as most major hospitals are concentrated in the capital city of Brisbane. We implemented a state-wide telehealth service to improve access for rural patients in a public bariatric service. We report our early experiences with this service. METHODS: We reviewed all patients seen in the Bariatric Telehealth Clinic from 2017 to 2019. Patients underwent consultation through video-link software at their local hospital with the multidisciplinary team in Brisbane (surgeon, dietician and clinical nurse). Distances from Brisbane and number of visits were calculated. Telehealth patients were contacted by phone to complete a survey regarding their experiences. This was a 17-question Likert-style survey with scores from 1 (strongly disagree) to 5 (strongly agree). RESULTS: A total of 85 new patients underwent their initial consultation via telehealth. Each patient had a variable number of in-person as well as telehealth consultations both before and after surgery. Mean distance from telehealth consultation site to Brisbane was 614 km (range 149-2472 km). In total, 41 (48%) completed the survey. With regard to telehealth saving time and money, improving access to bariatric care, and desire to use telehealth again, the mean score was 4 out of 5 or higher for all questions (i.e., agree or strongly agree). There was no identifiable post-operative complication that was caused or exacerbated by telehealth. CONCLUSION: Bariatric surgical telehealth appointments are feasible and preferred by most patients residing in rural and remote locations. Each consultation avoids significant travel time and cost for the patient and health service, with no obvious adverse outcomes. Telehealth improves equity and access to specialist services for rural and remote patients.

Stump appendicitis 5†years after laparoscopic appendicectomy.

A 31-year-old healthy man presented with right lower quadrant pain and tenderness, mild neutrophilia and clinical presentation consistent with appendicitis, despite undergoing a laparoscopic appendicectomy 5 years prior. CT scan demonstrated a caecal phlegmon, in the expected region of the appendiceal stump. The patient was taken for laparoscopy and a 2 cm inflamed appendiceal stump was encountered. A distal caecectomy was performed and the patient made an unremarkable recovery. Histological examination was consistent with acute inflammation of the appendiceal stump. Only a small number of case reports of stump appendicitis have been published so far. Correct identification and ligation of the appendiceal stump is crucial to prevent this complication. Although normally it is treated with completion appendicectomy, the optimal treatment approach for this condition has not been well established.

Campylobacter colitis: Rare cause of toxic megacolon.

INTRODUCTION: Campylobacter is the leading cause of bacterial diarrhoeal illness worldwide. Toxic megacolon is a rare but potentially devastating complication. PRESENTATION OF CASE: A 55year old female with liver cirrhosis, alcoholism and hepatitis C, presented with severe colitis and stool specimen positive for Campylobacter. She developed septic shock, multi-organ dysfunction syndrome and toxic megacolon unresponsive to medical therapy, and underwent a subtotal colectomy with end ileostomy. Despite initial improvement, the patient died on postoperative day 4. DISCUSSION: Early surgical consultation is essential as toxic megacolon may be complicated by perforation or uncontrolled bleeding; progressive colonic dilatation with clinical deterioration is also an important indication for surgery. CONCLUSION: Toxic megacolon should be considered in a patient with Campylobacter colitis who becomes critically unwell. Despite treatment, toxic megacolon is associated with a significant risk of mortality.

Training in General Surgery Ward Call: A Resident-Student Buddy System.

There is a paucity of literature regarding medical student experiences of after hours hospital ward call. It was observed at our institution that medical students had minimal experience in ward call, yet were required to undertake such shifts as interns after graduation. We implemented a buddy system in which a medical student shadowed a general surgery resident for a ward call shift. Final year medical students were recruited from the local university at a tertiary teaching hospital after institutional approval. Each student attended a 4 hour evening shift on a general surgery ward with a supervising resident. A survey detailing attitudes and expectations of ward call was completed before and after the experience. Nine students enrolled in the project. Familiarity of expectations of what is required of an intern on a ward call shift improved significantly after the experience (3.1/5 to 4.1/5, p = 0.002). After hours work experience was reported as useful both before and after the study (4.5/5 to 4.7/5, p = 0.47). Students and doctors involved unanimously felt the experience was worthwhile. After hours ward call experience is useful for a final year medical student. More studies are required to further define the role of after hours ward call experiences during medical training.

The use of gastrointestinal cocktail for differentiating gastro-oesophageal reflux disease and acute coronary syndrome in the emergency setting: a systematic review.

BACKGROUND: Differentiating acute chest pain caused by myocardial ischaemia from other, potentially more benign causes of chest pain is a frequent diagnostic challenge faced by Emergency Department (ED) clinicians. Only 30% of patients presenting with chest pain will have a cardiac origin for the pain, and gastro-oesophageal disorders are one of the common sources of non-cardiac chest pain, yet remain clinically difficult to differentiate from cardiac pain. AIM: A systematic review of the literature was conducted to locate and evaluate clinical trials comparing the use of an oral gastrointestinal (GI) cocktail (oral viscous lidocaine/ antacid ± anticholinergic) to standard diagnostic protocols (serial electrocardiograms (ECGs), serial biomarkers, imaging and/ or provocative testing) to differentiate emergency patients presenting with acute chest pain caused by gastro-oesophageal disease from those with other aetiologies. METHODS: Studies were identified by searching electronic databases, scanning reference lists of articles, and searching clinical trial databases for relevantly currently registered trials. The search included PubMed (1966 - present), Embase (1980 - present) and Cochrane Central Register of Controlled Trials (CENTRAL). The identified studies were evaluated with a modified QUADAS tool. RESULTS: A total of four studies were identified for inclusion in the review. Studies were of low methodological quality with heterogeneous results. There were no adequately powered and appropriately designed studies identified. DISCUSSION: Current diagnostic protocols for Acute Coronary Syndrome (ACS) revolve around early and serial ECG monitoring and cardiac biomarker testing, imaging and careful clinical examination. In patients with chest pain and suspected ACS, the use of a GI cocktail compared with standard diagnostic protocols (serial ECG and biomarkers and provocative testing or imaging) is not proven to improve accuracy of diagnosis, and cannot reliably exclude myocardial ischaemia.

Improving the efficiency of discharge summary completion by linking to preexisiting patient information databases.

The discharge summary (DS) is a document that contains the diagnosis, comorbidities, procedures, complications, and future treatment plan for a particular patient after an inpatient hospital stay. The DS is completed by junior medical staff and is delivered to the general practitioner (GP). DS completion is time consuming and tedious, and DSs are usually not completed within the recommended time frame after a patient is discharged. Time spent completing DSs correlate to junior doctor overtime, which costs the hospital money in overtime pay. Information that is required in the DS is generally already entered into numerous electronic information systems in the hospital, including the "electronic patient journey board" which lists all the patients in a given ward with their clinical information. This information is constantly updated by all staff in the hospital. A program was developed that transferred this information directly into the patient DS. Ten junior doctors in two departments kept daily records for one week of the time spent compiling DSs, the time at work and the actual overtime claimed, before and after the introduction of the intervention. The mean (± SD) time for DS compilation per week reduced by 2.8 (± 2.4) hours from 10.0 (±3.5) hours (p<0.01) and the mean overtime worked per week reduced by 2.8 (± 3.1) hours from 8.5 (± 4.4) hours (p<0.05). The mean overtime claimed reduced by 1.8 (± 2.8) hours from 5.3 (± 5.4) hours per week (p<0.05), resulting in reduction in mean overtime payment of $114.95 from $290.57 per doctor, per week. Extrapolating to the 60 ward based junior doctors, the potential annual savings for the hospital budget are over $350,000. Additionally, the number of DSs completed within 48 hours increased from 45% to 58%. In summary, the transfer of electronic data from the electronic patient journey board to the discharge summary program has yielded improvements in DS completion rates and overtime worked by medical staff, resulting in significant reduction in overtime costs.

Improving the quality of hospital discharge summaries utilising an electronic prompting system.

The discharge summary (DS) is a summary of an inpatient admission, patient's health state, and future treatment plans which is delivered to the patient's primary care provider. The DS is often incomplete, inaccurate, or unclear. The aim of this project was to improve the quality of the DS through the use of an electronic prompting system. The electronic prompting system was implemented in the acute medical and surgical wards of the hospital as an adjunct to a pre-existing, widely used hospital program that documents all the patients in a ward or belonging to a particular treating team. When using the program, a doctor enters information (with the assistance of the treating consultant) from a drop-down menu and is prompted to include common, departmental specific diagnoses, co-morbidities, complications, and procedures that were commonly missed or documented incorrectly in the DS. Fifteen DSs were randomly selected from a two month period immediately prior to the intervention period and were rated by an external, experienced general practitioner (GP) using a scoring system consistent with the Australian Medical Association Guidelines for quality DSs. Fifteen random DSs from a two month period, four months post-implementation were also rated by the same GP. The quality of the DS improved in all categories evaluated. The overall quality improved from mean (± SD) 2.86 ± 1.64 to 4.13 ± 0.92 out of 5 (p = 0.031). Additionally the implementation of the system was associated with improvements in documentation of the diagnosis, co-morbidities and other relevant clinical information. In summary, electronic prompting systems can improve the quality of DSs to ensure the information contained within the DS is more accurate and complete.

Surveillance of women at increased risk of breast cancer using mammography and clinical breast examination: further evidence of benefit.

Women with a significant family history of breast cancer are generally offered early surveillance by mammography and often clinical breast examination (CBE). The evidence base for surveillance has been questioned. We reviewed its effectiveness in terms of tumour size, lymph node status and survival in 7,475 women seen over a 22-year period in the Manchester Family History Clinic. We diagnosed 139 invasive and 26 in situ breast cancers. Seventy-six percent of the invasive cancers were screen detected, 65% node negative and 71% <2 cm in diameter at diagnosis. Twenty-one tumours were BRCA1 positive and were significantly more likely to be grade 3, ER/PR negative (p < 0.0001) and have a poorer survival. CBE contributed to 30% of cancer diagnoses and was responsible for discovery of nine mammographically occult tumours. The cost per quality life year was estimated at £13,080 for tumours detected by CBE and not by mammography. We conclude that screening by annual mammography and CBE between age 35-50 years and 18 monthly from 50 to 60 years may diagnose breast cancer in a less advanced state in terms of size and node status compared with symptomatic cancers and, apart from BRCA1 carriers, is likely to contribute to improved long-term outcome compared with no surveillance.

Predicting compliance in a breast cancer prevention trial.

The impact of chemoprevention trials can be hampered by poor participant compliance with the study medication. We used medication monitoring systems and pill count data to try to establish factors that may predict compliance with the International Breast Intervention Study (IBIS) and whether the participants went on to complete or benefit the trial. Women who took their trial medication in a regular pattern rather than randomly were more likely to be of benefit to the study (p = 0.003). For those women who failed to complete the study, compliance was shown to gradually reduce at each follow-up appointment. The taking of additional prescribed medication and not smoking were important factors in predicting completion (p = 0.04 and p = 0.047, respectively) and benefit (p = 0.037 and p = 0.031, respectively) to the study. Taking these factors into account when advising women at the start of a chemoprevention trial may be helpful in improving compliance.