The Supreme Court's decision in McCulloch v Forth Valley Health Board: Does it condone healthcare injustice?

The UK Supreme Court's recent judgement in McCulloch v Forth Valley Health Board clarifies the standard for the identification of 'reasonable' alternative medical treatments. The required standard is that of a reasonable doctor: treatments that would be accepted as proper by a responsible body of medical opinion. Accordingly, the assessment of consent involves a two-stage test: first, a 'reasonable doctor' test for identifying alternative treatments; followed by a 'reasonable person in the patient's position' test for identifying the material risks of these reasonable alternative treatments. The separation of consent into two stages is consistent with not only a certain conception of freedom but also a nuanced construct of respect for autonomy that has a normative base. Furthermore, reliance on a reasonable doctor in the first stage is in keeping with a sociological account of medical professionalism, which posits that only doctors, and none others, can determine what is a proper treatment. Yet, reliance on a reasonable doctor permits a plurality of standards for reasonableness, because differences in opinion among doctors are pervasive. The reasons for some differences might be acceptable as unavoidable imperfections in medical decision-making to a reasonable person. But reasons for other differences might be objectionable; and the resultant inequalities in medical treatments would be considered unfair. One solution is to make the plurality of reasonable alternatives available to the patient, but this would introduce practical uncertainty and it is rejected by the Court. The Court's approach may be pragmatic; however, it seems to allow avoidable injustice in healthcare.

Rawlsian justice in healthcare: a response to Cox and Fritz.

Cox and Fritz state the central problem as the absence of a framework for healthcare policy decisions; but, they overlook the theoretical underpinnings of public law. In response, they propose a two-step procedure to guide fair decision-making. The first step relies on Thomas Scanlon's 'contractualism' for stakeholders to consider whether, or not, they could reasonably reject policy proposals made by others; then in the second step, John Rawls's principles of justice are applied to these proposals; a fair policy requires to pass both steps. I argue that Cox and Fritz misinterpret Rawls. His theory has two stages: first, public reason is used to generate principles of justice; second, public reason is used to interpret and apply these principles. The second stage requires that proposals are based on the principles of justice from the first stage, and these proposals have to be acceptable to reasonable persons. Thus, Rawls's theory does not need Scanlonian supplementation. Moreover, the application of Rawls's theory in Cox and Fritz's model is confusing. In any case, the problems with applying Rawlsian justice to healthcare can be located elsewhere. First, Rawls's theory would treat healthcare simply as a 'primary good' or resource. Social justice ought to, instead, consider healthcare as an opportunity, in the manner conceived by Amartya Sen. Second, Rawlsian justice rests, ultimately, on the conception of a reasonable person; until and unless the characteristics of reasonable stakeholders are clarified, any model of health justice will remain hostage to the unreasonable.

Does the General Medical Council's 2020 guidance on consent advance on its 2008 guidance?

The General Medical Council renewed its guidance on consent in 2020. In this essay, I argue that the 2020 guidance does not advance on the earlier, 2008 guidance in regard to treatments that doctors are obliged to offer to patients. In both, doctors are instructed to not provide treatments that are not in the overall benefit, or clinical interests, of the patient; although, patients are absolutely entitled to decline treatment. As such, consent has two aspects, and different standards apply to each aspect. To explore this paradigm, I propose the reconceptualisation of consent as a person's freedom to achieve treatment, using Amartya Sen's approach. Sen explains that freedom has two aspects: process and opportunity. Accordingly, a patient's freedom to achieve treatment would comprise a process for the identification of proper treatment, followed by an opportunity for the patient to accept or decline this treatment. As per Sen, the opportunity aspect is to be assessed by the standard of public reason, whereas the standard for the process aspect is variable and contingent on the task at hand. I then use this reconceptualised view of consent to analyse case law. I show that senior judges have conceived the patient's opportunity to be encompassed in information, which is to be decided by public reason. On the other hand, the process aspect relies on the private reason of medical professionals. Given the nature of professionalism, this reliance is inescapable, and it is maintained in the case law that is cited in both guidances.

Surveillance Is Important After Surgical Excision of Giant Fibrovascular Polyps of the Esophagus.

Giant fibrovascular polyps of the esophagus are rare benign tumors arising from the cervical esophagus or hypopharynx. Radiologic and endoscopic investigation may struggle to identify a stalk or to delineate the tumor as luminal or submucosal in origin. Excision is advised, although the diagnosis, and therefore the optimal operative approach, may not be apparent until the time of operation. Individual case reports describe the technical success of surgical excision but rarely include follow-up. Our case series highlights the range of approaches for surgical excision and also the importance of long-term follow-up because of the risk of recurrence and potential for airway obstruction.

Neurostimulation of the gastrointestinal tract: review of recent developments.

OBJECTIVE: Neurostimulation is one manifestation of neuromodulation of the gastrointestinal (GI) tract. This manuscript reviews the history of neurostimulation of the GI tract with emphasis on current methods of stimulation. MATERIALS AND METHODS: A review was completed of the current research on GI neurostimulation methods with an emphasis on their clinical applications. RESULTS: Upper GI disorders can be modulated with both temporary (placed endoscopically or surgically) or permanent (placed surgically) gastric electrical stimulation (GES) devices. The current GI neurostimulation of stomach (GES) devices have been used in both children and adults, and some patients have been followed in excess of 15 years with good long-term results. Similar GES devices also have been used for a variety of lower GI disorders, including constipation and fecal incontinence, for a number of years. CONCLUSIONS: GI neurostimulation, as a type of neuromodulation, has been demonstrated to function at several locations in the GI tract for a variety of disorders. The future of neurostimulation in the GI tract will likely be influenced by a better understanding of pathophysiology as well as the development of new techniques and devices for neuromodulation.

Informed decision-making for bariatric surgery: benefits, risks, uncertainties and choices.

Decision-making is a critical aspect of good surgical care, and this principle is particularly important in bariatric surgery. Adequate communication of information to patients is essential in order to facilitate optimal uptake of bariatric surgery and choice of the most suitable procedure. This article reviews the most relevant advances in understanding of long-term efficacy associated with gastric banding, gastric bypass and sleeve gastrectomy.

Gastric electrical stimulation for treatment of clinically severe gastroparesis.

BACKGROUND: Severe, drug-resistant gastroparesis is a debilitating condition. Several, but not all, patients can get significant relief from nausea and vomiting by gastric electrical stimulation (GES). A trial of temporary, endoscopically delivered GES may be of predictive value to select patients for laparoscopic-implantation of a permanent GES device. MATERIALS AND METHODS: We conducted a clinical audit of consecutive gastroparesis patients, who had been selected for GES, from May 2008 to January 2012. Delayed gastric emptying was diagnosed by scintigraphy of ≥50% global improvement in symptom-severity and well-being was a good response. RESULTS: There were 71 patients (51 women, 72%) with a median age of 42 years (range: 14-69). The aetiology of gastroparesis was idiopathic (43 patients, 61%), diabetes (15, 21%), or post-surgical (anti-reflux surgery, 6 patients; Roux-en-Y gastric bypass, 3; subtotal gastrectomy, 1; cardiomyotomy, 1; other gastric surgery, 2) (18%). At presentation, oral nutrition was supplemented by naso-jejunal tube feeding in 7 patients, surgical jejunostomy in 8, or parenterally in 1 (total 16 patients; 22%). Previous intervention included endoscopic injection of botulinum toxin (botox) into the pylorus in 16 patients (22%), pyloroplasty in 2, distal gastrectomy in 1, and gastrojejunostomy in 1. It was decided to directly proceed with permanent GES in 4 patients. Of the remaining, 51 patients have currently completed a trial of temporary stimulation and 39 (77%) had a good response and were selected for permanent GES, which has been completed in 35 patients. Outcome data are currently available for 31 patients (idiopathic, 21 patients; diabetes, 3; post-surgical, 7) with a median follow-up period of 10 months (1-28); 22 patients (71%) had a good response to permanent GES, these included 14 (68%) with idiopathic, 5 (71%) with post-surgical, and remaining 3 with diabetic gastroparesis. CONCLUSIONS: Overall, 71% of well-selected patients with intractable gastroparesis had good response to permanent GES at follow-up of up to 2 years.

Long-term follow-up after laparoscopic sleeve gastrectomy: 8-9-year results.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a definitive bariatric procedure despite the sparse long-term follow-up data. On the basis of extensive experience with the open Magenstrasse and Mill operation, we began practice of LSG in 2000. The objective of the present study was to analyze 8-9 years of our follow-up data for LSG at a university hospital in the United Kingdom. METHODS: From January 2000 to December 2001, 20 patients underwent LSG. A 32F bougie was used for calibration in all cases. RESULTS: The preoperative median body mass index was 45.8 kg/m(2) (range 35.8-63.7), and 9 patients (45%) were superobese (body mass index ≥ 50 kg/m(2)). For LSG as a definitive bariatric procedure, 8-9-year follow-up data were available for 13 patients. Of the remainder, 4 patients underwent revision surgery and 3 were lost to follow-up after 2 years. For the entire cohort, the median excess weight loss (EWL) was 73% (range 13-105%) at 1 year, 78% (range 22-98%) at 2 years, 73% (range 28-90%) at 3 years, and 68% (range 18-85%) at 8 or 9 years (P = .074). Of the 13 LSG-only patients with 8-9 years of follow-up, 11 (55% of the starting cohort) had >50% EWL at 8 or 9 years. No significant difference was found in the initial body mass index between the LSG-only patients with >50% EWL and others (45.9 kg/m(2), range 35.8-59.4 versus 45.7 kg/m(2), range 38.9-63.7, respectively; P = .70). The LSG-only patients with >50% EWL had a marginally significantly greater EWL at 1 year compared with the others (76%, range 48-103% versus 45%, range 13-99%, respectively; P = .058). CONCLUSION: At 8-9 years of follow-up, 55% of patients had >50% EWL from LSG as a definitive bariatric procedure.

Use of the obesity surgery mortality risk score to predict complications of laparoscopic bariatric surgery.

BACKGROUND: This study aimed to evaluate the role of the Obesity Surgery Mortality Risk Score (OS-MRS) to predict the risk of post-operative adverse events, in addition to death, from any laparoscopic bariatric procedure. METHODS: The OS-MRS was applied to consecutive patients at a single hospital during October 2008-September 2009. The composite end point comprised one or more of the following adverse events: mortality, re-intervention, re-admission to hospital, venous thromboemobolism, or blood transfusion. RESULTS: There were 381 patients (men, 19%). The median age was 43 years (range, 19-67 years), with 42% patients aged ≥45 years. The median weight was 126 kg (75-295 kg) and median BMI 46 kg/m(2) (30-84 kg/m(2)); 37% had BMI ≥50 kg/m(2). Twenty-seven percent of patients had hypertension and 3% had a past history of venous thromboembolism. The OS-MRS classes were A (60.1%), B (35.9%), or C (4.0%). Operations comprised adjustable gastric band (37%), Roux-en-Y gastric bypass (54%), sleeve gastrectomy (8%), or biliopancreatic diversion (1%). Of the operations, 1.6% were revisional procedures. An adverse outcome occurred in 19 patients, with distribution in 3.5% of class A patients, 5.8% of class B, and 20.0% of class C (A vs. B, P = 0.451; A vs. C, P = 0.002; B vs. C, P = 0.025). There was one death: OS-MRS class C. On multivariate analysis, OS-MRS (class C vs. A or B; Odds Ratio [OR], 4; P = 0.050) and type of operation (band vs. bypass or sleeve; OR, 9.2; P = 0.033) were independently predictive of the composite end point. CONCLUSION: OS-MRS and type of the bariatric operation are independently predictive of the risk of post-operative adverse events.

Two-stage removal of giant fibrovascular polyp of the oesophagus.

A patient presented with several months' history of dysphagia, chest pain, symptoms of regurgitation and weight loss. He underwent an upper gastrointestinal endoscopy, which revealed a giant polyp of the oesophagus. After confirming the diagnosis of giant fibrovascular polyp of the oesophagus, the patient underwent a two-stage division of the stalk and retrieval of the polyp. The postoperative period was uneventful and the patient was asymptomatic at the time of discharge. He is being followed up with a plan for surveillance endoscopy in a year.

Randomized clinical trial of torsional versus linear mode ultrasonically activated devices for laparoscopic cholecystectomy.

BACKGROUND: Conventional ultrasonically activated devices use linear mode vibration. Torsional mode ultrasonically activated device (TM) that oscillate around an arc have been recently introduced in the hope that the design may result in faster cutting and better hemostasis. METHODS: Patients undergoing elective laparoscopic cholecystectomy were randomized to TM or linear mode ultrasonically activated device (LM). Intraoperative events were recorded. Postoperatively, a sample of suction fluid was analyzed for hemoglobin concentration to calculate intraoperative blood loss. RESULTS: Seventy-five patients were randomized to TM and 76 patients to LM. Median blood loss was 5 (interquartile range (IQR), 1-19.7) ml with TM and 10.5 (IQR, 2.3-23) ml with LM (p = 0.105). The 95% confidence interval for the difference in median operative blood loss was -1.3 to +9.5 ml. Median gallbladder dissection time was similar in both groups (17 (IQR 11-29) minutes for TM vs. 21 (IQR, 12-29) minutes for LM; p = 0.248). Other modalities of hemostasis were required in 14 patients (19%) in the TM group compared with 21 patients (28%) in the LM group. One patient in the LM group developed postoperative hemoperitoneum and required urgent laparoscopic exploration. No patient required blood transfusion or suffered any other significant complication. CONCLUSION: TM has similar effectiveness to LM for laparoscopic cholecystectomy. REGISTRATION NUMBER: ISRCTN87527062 ( http://www.controlled-trials.com ).

Neoadjuvant chemotherapy and surgery for esophageal adenocarcinoma: prognostic value of circumferential resection margin and stratification of N1 category.

BACKGROUND: In the UK, it is standard practice to treat esophageal adenocarcinoma with neoadjuvant chemotherapy (no radiation) and surgery. We examined the prognostic value of the status of the circumferential resection margin (CRM) and stratification of the N1 category into 1-4 nodes or > or = 5 nodes. METHODS: Between 2000 and 2006, 105 patients with radiologically staged T3, T4 or N1 esophageal adenocarcinoma had preoperative chemotherapy. One hundred and one patients had an Ivor Lewis operation with two-field lymphadenectomy, three had a transhiatal operation and one had a three-incision operation. CRM was assessed by painting the specimen with India ink and transverse sections at 5-10 mm intervals. The CRM was considered positive (CRM+) if malignant cells were within 1 mm of the inked margin. RESULTS: There were 87 men. The median age was 61 years (range 37-81 years). Median lymph node yield was 28 (4-77); 86 patients (83%) had > or = 18 nodes. Seventy-four patients (70%) had N1 disease, with 1-4 involved nodes in 41 patients (39%) and > or = 5 nodes in 33 patients (31%). The CRM was positive in 38 patients (36%). On multivariate analysis, nodal metastasis [N0 versus N1; hazard ratio (HR) 3.3, 3-year survival 80% versus 40%; P = 0.004], CRM status (CRM- versus CRM+: HR 2.6, 3-year survival 64% versus 26%; P = 0.002) and vascular invasion (V0 versus V1: HR 2.2, 3-year survival 67% versus 39%; P = 0.014) retained independently significant prognostic value. N1 patients with 1-4 nodes had longer survival than those with > or = 5 nodes (56% versus 21%; P < 0.001). CONCLUSIONS: CRM involvement and stratification of the N1 category are independent prognostic factors after multimodal therapy for esophageal adenocarcinoma.