A Systematic Review of Online Patient Resources to Support Shared Decision Making for Laparoscopic Cholecystectomy.

BACKGROUND: RCS Eng, the Royal College of Surgeons of England, has published much information with regard to the consenting process. A majority of patients seek health information through online resources as well as discussing with the care givers. Therefore, it is necessary that online material is both of high quality and reliable for patients. We aimed to evaluate the quality and standard of the online patient information on laparoscopic cholecystectomy to help in the consenting process. METHODS: A search was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sources were assessed using five validated scoring tools: Flesch-Kincaid Reading Ease Score (readability), DISCERN and IPDAS scores (quality of content) and HONcode and the Information Standard Certification (standards of accreditation). RESULTS: The average readability of all websites was higher than recommended for patient literature. Less than half of the sources had received HONcode or Information Standard accreditation. On grading of quality and content, across validated scoring tools, no source achieved the minimum recommended level. CONCLUSION: Online patient information related to laparoscopic cholecystectomy is of poor quality. We recommend a multidisciplinary approach to participate in publishing more readable online resources of a higher standard to help patients and clinicians in consent and shared decision making.

Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-en-Y Gastric Bypass in Elderly Bariatric Patients: Safety and Efficacy-a Systematic Review and Meta-analysis.

INTRODUCTION: Obesity is a chronic disease due to excess fat storage, a genetic predisposition, and environmental contribution where surgery offers a viable treatment option. The surgical treatment of obesity in the elderly population (> 55 years) remains controversial. PURPOSE: To evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in elderly bariatric patients. MATERIALS AND METHODS: Data was sourced from MEDLINE, EMBASE, CINAHL, PubMed, and Cochrane databases for peer-reviewed, randomized controlled trials, and observational studies in the English language were searched from the year 1991 until 2019. From the extracted data, early and late procedural complications and mortality were used as safety outcomes. Weight loss was the primary outcome for effectiveness while the resolution of obesity-related comorbidities was included as secondary outcomes. The Review Manager (Rev Man 5.3)™ software was used for statistical analysis. RESULTS: Of the forty-one screened studies, nine studies were included in the final analysis. There was no difference between LSG and LRYGB regarding early complications and mortality 3.6% versus 5.8% (p = 0.15) and 0.1% versus 0.8% (p = 0.27). Patients who underwent LRYGB had more late complications compared with those who underwent LSG (0.07% and 0.03%, p = 0.001). There was no difference in terms of weight loss at the end of 1 year. Patients who underwent LRYGB had a better resolution of obesity-related comorbidities, not statistically significant. CONCLUSION: LRYGB has better efficacy when compared with LSG. However, high-risk elderly patients should be considered for LSG given the lesser morbidity and comparable efficacy with LRYGB.

Systematic review of online patient resources to support shared decision making for bariatric surgery.

BACKGROUND: Bariatric surgery is an effective treatment for obesity and the associated comorbidities but carries a number of important risks. The Royal College of Surgeons advises patients to utilise online resources as part of the shared decision-making process. The aim of this study was to assess the quality of online materials on bariatric surgery. METHODS: A systematic review was performed of online healthcare information relating to bariatric surgery. Common search terms were entered into three main search engines according to a defined search strategy. Websites were assessed according to readability (Flesch-Kincaid Reading Ease Score), quality and content (DISCERN and IPDAS Scores) and standards of accreditation (HONcode and Information Standard Certification). This systematic review was registered on the PROSPERO database CRD42019132188. RESULTS: The average readability of all sources extracted was higher than that recommended for patient literature. Over half the studies contained had received HONcode or Information Standard accreditation, suggesting a quality marker for the content. On grading of quality and content, across validated scoring tools, no source achieved the minimum recommended level. CONCLUSION: Patient information online related to bariatric surgery is of poor quality. Such resources require improvement to aid in the shared decision-making process.

Variation in esophageal anastomosis technique-the role of collaborative learning.

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

Single-incision laparoscopic reversal of Hartmann's operation through the stoma site: comparative outcomes with conventional laparoscopic and open surgery.

AIM: Restoration of bowel continuity after Hartmann's procedure (RoH) can be challenging and associated with considerable morbidity. A technique using single-incision laparoscopic surgery through the stoma site (SIL RoH) has been shown to be feasible and safe. In this study, we compared clinical outcomes of SIL RoH with conventional laparoscopic surgery (CL) and open surgery (OS). METHODS: This was a retrospective analysis of a prospectively maintained database between 2007 and 2017 in a UK colorectal unit. The access technique was decided by the surgeon on a case by case basis. RESULTS: A total of 106 patients underwent RoH. It was carried out for diverticular disease (n = 71, 67.6%), cancer (n = 19, 17.9%) and anastomotic leak (n = 4, 3.8%). The remainder (n = 12, 11.3%) were for miscellaneous reasons including trauma. Most RoHs were performed via OS (n = 87, 81.1%). The most common intended approaches for RoH were SIL (n = 56, 52.8%) and OS (n = 34, 32.1%) with fewer starting with CL (n = 16, 15.1%). Conversion to OS took place in five (8.9%) patients with SIL and six (37.5%) with CL (P = 0.005). Postoperative complications occurred in 17 (30.4%) for SIL, seven (43.8%) for CL and 17 (50.0%) for OS (P = 0.162). Median operating time for SIL was 146 min (range 44-389), 211 min (109-320) for CL and 211 min (85-420) for OS (P < 0.001). Median length of stay was 4 days (2-44) for SIL compared to 6 (3-34) for CL and 7 (4-34) for OS (P < 0.001). Discharge on or before day 5 was achieved in 41 (74.5%) patients for SIL compared to six (37.5%) for CL and seven (20.6%) for OS (P < 0.001). CONCLUSION: Compared to OS and CL, SIL RoH appears to have shorter operating times and hospitalization, with no discernible difference in morbidity; this finding requires further evaluation in a randomized setting.

Gastrointestinal stromal tumours (GISTs): an insight into clinical practice with review of literature.

BACKGROUND: Gastrointestinal stromal tumours (GISTs) are rare mesenchymal tumours of the gastrointestinal tract. We retrospectively reviewed the clinical management of all patients with GIST presenting to a regional multidisciplinary upper gastrointestinal cancer group in the north of England. METHODS: Clinical, pathological, immunohistochemical treatment strategies, follow-up and outcome data on all patients with GIST between 2007 and 2012 were reviewed. Tumours were categorised by risk according to the National Institutes of Health (NIH) and AFIP models. RESULTS: 36 (85.7%) of 42 tumours were located in the stomach, 5 (11.9%) in the small intestine and 1 (2.4%) in the oesophagus. Median age of patients was 68 (range 43-91) years. 24 patients (57.1%) were female. Tumour size ranged from 1.0  to 12.7 cm with mean size of 5.46 cm. Metastasis was present in 19 (45.2%) patients at diagnosis with distant metastases in 12 patients. Liver was the most common site of metastases. Histology and immunohistochemical analysis was available in 32 (76.2%) patients. Most common histology was spindle cell morphology 17/32 (53.1%) followed by epithelioid 9/32 (28.1%) and mixed morphology 5/32 (15.6%). The positive rate for KIT protein (CD117) was 90.6%, while that for CD34 was 75.0%. 12/25 (48.0%) and 8/23 (34.8%) patients were categorised as high risk as per NIH and AFIP risk scores, respectively. 23/42 (54.8%) patients underwent surgical resection, after which 5/23 (21.7%) had adjuvant imatinib therapy. Imatinib was given as primary therapy in 14/42 (33.3%) patients. CONCLUSIONS: Surgery alone may not be a curative treatment for GISTs. Targeted therapy with imatinib may play an important role in the treatment of GISTs. Further risk categorisation models may be needed to evaluate GIST behaviour and prognosis.

Primary squamous cell carcinoma of the stomach: a rare entity.

A 73-year-old man presented acutely with upper gastrointestinal (GI) haemorrhage. Upper GI endoscopy was suggestive of a pancreatic or submucosal duodenal neoplasm invading the stomach. He underwent laparoscopically assisted distal gastrectomy. Histopathological examination showed the rare entity of primary gastric squamous cell carcinoma. He underwent adjuvant chemotherapy and remains disease free at 6 months.

Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery.

BACKGROUND: Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery. METHODS: Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation. RESULTS: Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204). CONCLUSION: Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. REGISTRATION NUMBER: ISRCTN43730758 (http://www.controlled-trials.com).

Prognostic value of hypoxia inducible factor 1α in esophageal squamous cell carcinoma.

Hypoxia inducible factor 1α (HIF 1α) plays a major role in the pleitropic response observed secondary to hypoxic conditions in tumors. Its expression in the tumor cells has been correlated to tumor aggressiveness and prognosis in squamous cell carcinoma (SCC) of the esophagus in Far Eastern population, but limited information is available on the prognostic role of HIF 1α in SCC of esophagus in European population. This information may help in choosing appropriate therapeutic strategies and possibly developing a monoclonal antibody with therapeutic potential targeting the HIF 1α. Tumor samples from 36 patients diagnosed with SCC of the esophagus were collected. Prepared tissue sections were stained with validated and specific monoclonal antibodies for HIF 1α and the expression was correlated with the disease pattern and survival. Out of 36 patients, 17 patients showed low and 19 high expression of HIF 1α. There was no difference in the disease-free and overall survival between these two groups (P > 0.05, log rank test). Regression analysis showed that HIF 1α was not an independent prognostic factor for survival (P > 0.05). HIF 1α did not show prognostic value in SCC of the esophagus in our study on European population, in agreement with previous studies. Novel strategies on the therapeutic manipulation of HIF 1α in cancer are to be explored further and may have a role to play in improving treatment outcome.

Peer review practices in biomedical literature: a time for change?

OBJECTIVE: The purpose of this study was to collect the opinions of a cross section of published authors on current practices concerning peer review in biomedical publishing. METHODS: A questionnaire on various aspects of peer review was emailed to authors, whose manuscripts were published in Gut or the British Journal of Surgery between 2001 and 2006. Authors were asked to base their responses on their overall experience with peer review in biomedical literature and not with that one particular journal. RESULTS: Most respondents felt that peer review is an effective quality control mechanism and does help improve manuscripts. Although some felt that it may cause delays in publication, lead to some research being lost and may not prevent all research-related fraud, most authors felt that there was still a strong role for the peer review process as it exists today. CONCLUSION: An overwhelming majority of authors in our study approved of the current peer review practices in biomedical literature. A minority did however seem concerned. We discuss here the surrounding issues.

Use of fistula director to enlarge the port site opening to retrieve a stone packed bulky gall bladder during laparoscopic cholecystectomy: a simple and safe technique.

Retrieval of the gall bladder through the port site opening is technically difficult and challenging when it is bulky either due to packed multiple calculi or a large solitary calculus. We describe in this article a simple technique that involves enlargement of the port site opening to facilitate the gall bladder removal in these difficult situations, using a scalpel and a fistula grooved director.

A non-contact complete knee dislocation with popliteal artery disruption, a rare martial arts injury.

Complete knee dislocation is a rare injury and an associated incidence of popliteal artery damage ranges from 16-60% of cases. It occurs commonly in road traffic accidents and in high velocity trauma where significant contact remains as the usual mode of injury. We describe a rare case of non-contact knee dislocation with popliteal artery injury sustained while practising Aikido, a type of martial art. This patient successfully underwent closed reduction of the knee with an emergency vein bypass graft. Similar injury in association with Aikido has not been described in the English literature previously. Various martial art injuries are briefly discussed and safety recommendations made.

The role of surgery in pseudomembranous enterocolitis.

Pseudomembranous enterocolitis is an inflammatory bowel disorder caused by Clostridium difficile toxins. Classical presentation includes abdominal pain, pyrexia, diarrhoea and leucocytes. The management is mainly conservative but in extreme cases surgery is necessary. Resectional procedures (colectomy) carry a better prognosis than diversion procedures (colostomy). A careful history, a high index of suspicion, and early diagnosis and treatment would reduce the associated morbidity and mortality of this condition. The aetiopathogenesis, pathology, clinical presentation, diagnosis, differential diagnosis, complications, medical and surgical management are reviewed, and three case reports briefly discussed. A management algorithm is also suggested.

Myxoglobulosis, a rare variant of appendiceal mucocele, occurring secondary to an occlusive membrane.

A 77-year-old man presented with altered bowel habit and episodic right lower abdominal discomfort. A barium enema showed a large smooth filling defect in the caecum and at operation his appendix was seen to be hugely distended. Pathological examination showed myxoglobulosis, a rare variant of mucocele of the appendix. The appendiceal orifice was completely occluded by an imperforate membrane with no communication between the appendix and caecum. This is the first published report in the English language of appendiceal myxoglobulosis in association with such an occlusive membrane.