Laparoscopic Adjustable Gastric Band Slippage Rates Following Laparoscopic Gastric Band Insertion: a Single Centre Experience.

INTRODUCTION: Laparoscopic adjustable gastric bands (LAGB) are placed around the superior aspect of the stomach to aid weight loss and co-morbidity resolution in morbidly obese patients. Slippage of the LAGB from its original position to lower in the fundus of the stomach leads to gastric obstruction, and sometimes ischaemia or perforation, necessitating LAGB repositioning or removal. This study aimed to identify the incidence of LAGB slippage, as well as predisposing factors that may influence its development. METHODS: All LAGBs inserted at one centre, via a pars flaccida technique, by four Bariatric specialist consultants, were reviewed utilising a prospectively maintained Bariatric database, computer records and case notes review. RESULTS: Seven hundred nineteen LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip rate 3.1 %). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 years slip vs. 45 years non-slip; p = 0.027), higher median total excess weight loss (64 % slip vs. 36 % non-slip; p < 0.001) and higher mean excess weight loss per month (2.41 % slip vs. 1.00 % non-slip; p < 0.001). There was no significant effect by sex, BMI at insertion or band type. CONCLUSIONS: Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.

Update on the management of cholangiocarcinoma.

Cholangiocarcinoma (CC) is a rare cancer arising from the epithelium of the biliary tree, anywhere from the small peripheral hepatic ducts to the distal common bile duct. Classification systems for CC typically group tumours by anatomical location into intrahepatic, hilar or extrahepatic subtypes. Surgical resection or liver transplantation remains the only curative therapy for CC, but up to 80% of patients present with advanced, irresectable disease. Unresectable CC remains resistant to many chemotherapeutic agents, although gemcitabine, particularly in combination with other agents, has been shown to improve overall survival. Ongoing investigation of biological agents has also yielded some promising results. Several novel interventional and endoscopic techniques for the diagnosis and management of non-operable CC have been developed: initial results show improvements in symptoms and progression-free survival, but further randomised studies are required to establish their role in the management of CC.

Improved outcomes in the management of high-risk incisional hernias utilizing biological mesh and soft-tissue reconstruction: a single center experience.

INTRODUCTION: Repair of incisional hernias is complex in the setting of previous/current infection, loss of domain and bowel involvement, and is often on the background of significant co-morbidities. Reported repair techniques are associated with significant morbidity and led our unit to develop a novel technique for complex incisional hernia repair. METHODS: A retrospective case notes review of all high-risk (Ventral Hernia Working Group grade 2-4) incisional hernia repairs was undertaken. Standardized repair involved resection of attenuated soft tissue and hernia sac (bioburden reduction), component separation (where necessary), intra-peritoneal Strattice™ biological mesh insertion, midline fascial closure, and soft-tissue reconstruction, performed in combination with a plastic surgeon as a single-stage procedure. RESULTS: A total of 58 patients underwent hernia repair between February 2009 and September 2012 (median age 59 years; 59 % female). Eleven patients (19 %) were grade 4, 19 (33 %) were grade 3, and 28 (48 %) were grade 2. Nineteen (33 %) were recurrent hernias, and midline fascial closure was achieved in 52 (90 %). Early complications included 15 (26 %) surgical-site occurrences, three (5 %) respiratory complications, two (3 %) cardiac complications, and two (3 %) urinary tract infections. Follow-up has revealed three (5 %) asymptomatic hernia recurrences and no patients requiring mesh explantation. CONCLUSIONS: This technique was associated with a low risk of surgical site occurrences and hernia recurrence, with no requirements for mesh explantation. Repair of such complex incisional hernias remains challenging, and further randomized controlled trials are required to elucidate the optimal method of closure and mesh type.

Perforation as a rare presentation of gastric gastrointestinal stromal tumours: a case report and review of the literature.

INTRODUCTION: Gastrointestinal stromal tumours (GISTs) are the most common connective tissue neoplasms of the gastrointestinal tract, the most common clinical presentation of which is with abdominal pain or gastrointestinal bleeding. METHODS: We describe a case of a perforated gastric GIST as well as reviewing the relevant published literature. RESULTS: A 51-year-old woman presented to the acute assessment unit with a 1-day history of severe epigastric pain on a background of longstanding reflux symptoms. Radiological investigation demonstrated a perforated mass in the gastric antrum and the patient subsequently underwent an emergency distal gastrectomy. She recovered well postoperatively and was discharged home. Her condition remains stable six months following surgery. Histological analysis revealed the perforated lesion to be a GIST. A PubMed search suggests that this is the first English report to describe a perforated gastric GIST. Six further published reports (written in English or with an English abstract) describing the presentation of small bowel GISTs with perforation are reviewed. CONCLUSIONS: We present the first English report of a perforated gastric GIST. More common presentations include abdominal pain and gastrointestinal bleeding. Although rare, GISTs should be considered in the differential diagnoses of perforated gastrointestinal masses.

Pilocytic astrocytoma mimicking craniopharyngioma: a case series.

Although they are one of the most common brain tumours in childhood, pilocytic astrocytomas are rare in adulthood. We report a series of three pilocytic astrocytomas presenting as an intra/suprasellar mass in the fourth to sixth decades of life. All three radiologically mimicked the appearance of a craniopharyngioma, thus representing a potential radiological and diagnostic pitfall. In this series all three patients underwent successful operative management and have remained well throughout follow-up. The majority of information concerning pilocytic astrocytomas is derived from paediatric populations and so only limited and often conflicting data exist for pilocytic astrocytomas developing in adulthood. Decisions regarding treatment of pilocytic astrocytomas in adults must be made on a multidisciplinary, case-by-case basis.

Review article: surgical, neo-adjuvant and adjuvant management strategies in biliary tract cancer.

BACKGROUND: The majority of patients with cholangiocarcinoma present with advanced, irresectable tumours associated with poor prognosis. The incidence and mortality rates associated with cholangiocarcinoma continue to rise, mandating the development of novel strategies for early detection, improved resection and treatment of residual lesions. AIM: To review the current evidence base for surgical, adjuvant and neo-adjuvant techniques in the management of cholangiocarcinoma. METHODS: A search strategy incorporating PubMed/Medline search engines and utilising the key words biliary tract carcinoma; cholangiocarcinoma; management; surgery; chemotherapy; radiotherapy; photodynamic therapy; and radiofrequency ablation, in various combinations, was employed. RESULTS: Data on neo-adjuvant and adjuvant techniques remain limited, and much of the literature concerns palliation of inoperable disease. The only opportunity for long-term survival remains surgical resection with negative pathological margins or liver transplantation, both of which remain possible in only a minority of selected patients. Neo-adjuvant and adjuvant techniques currently provide only limited success in improving survival. CONCLUSIONS: The development of novel strategies and treatment techniques is crucial. However, the shortage of randomised controlled trials is compounded by the low feasibility of conducting adequately powered trials in liver surgery, due to the large sample sizes that are required.

Coil migration--a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms.

INTRODUCTION: We describe a case of metallic, angiographic coil migration, following radiological exclusion of a gastroduodenal artery pseudoaneurysm secondary to chronic pancreatitis. PATIENTS AND METHODS: A 55-year-old man presented to the out-patient clinic with chronic, intermittent, post-prandial, abdominal pain, associated with nausea, vomiting and weight loss. He was known to have chronic pancreatitis and liver disease secondary to alcohol abuse and previously underwent angiographic exclusion of a gastroduodenal artery pseudoaneurysm. During subsequent radiological and endoscopic investigation, an endovascular coil was discovered in the gastric pylorus, associated with ulceration and cavitation. This patient was managed conservatively and enterally fed via naso-jejunal catheter endoscopically placed past the site of the migrated coil. This patient is currently awaiting biliary bypass surgery for chronic pancreatitis, and definitive coil removal will occur concurrently. CONCLUSIONS: Literature review reveals that this report is only the eighth to describe coil migration following embolisation of a visceral artery pseudoaneurysm or aneurysm. Endovascular embolisation of pseudoaneurysms and aneurysms is generally safe and effective. More common complications of visceral artery embolisation include rebleeding, pseudoaneurysm reformation and pancreatitis.

Review article: pancreatic renin-angiotensin systems in health and disease.

BACKGROUND: In addition to the circulating (endocrine) renin-angiotensin system (RAS), local renin-angiotensin systems are now known to exist in diverse cells and tissues. Amongst these, pancreatic renin-angiotensin systems have recently been identified and may play roles in the physiological regulation of pancreatic function, as well as being implicated in the pathogenesis of pancreatic diseases including diabetes, pancreatitis and pancreatic cancer. AIM: To review and summarise current knowledge of pancreatic renin-angiotensin systems. METHODS: We performed an extensive PubMed, Medline and online review of all relevant literature. RESULTS: Pancreatic RAS appear to play various roles in the regulation of pancreatic physiology and pathophysiology. Ang II may play a role in the development of pancreatic ductal adenocarcinoma, via stimulation of angiogenesis and prevention of chemotherapy toxicity, as well as in the initiation and propagation of acute pancreatitis (AP); whereas, RAS antagonism is capable of preventing new-onset diabetes and improving glycaemic control in diabetic patients. Current evidence for the roles of pancreatic RAS is largely based upon cell and animal models, whilst definitive evidence from human studies remains lacking. CONCLUSIONS: The therapeutic potential for RAS antagonism, using cheap and widely available agents, and may be untapped and such roles are worthy of active investigation in diverse pancreatic disease states.

The role of ¹8fluoro-deoxy glucose combined position emission and computed tomography in the clinical management of anal squamous cell carcinoma.

AIM: Anal squamous cell carcinoma (SCC) is uncommon in the western world but continues to increase in incidence. Optimal treatment and outcome are dependent upon pretreatment staging strategies. We evaluate the role of ¹8fluoro-deoxyglucose (¹8FDG) combined position emission and computed tomography (PETCT) in the management of anal SCC. METHOD: Patients with a histologically confirmed anal SCC underwent standard staging investigations, including computed tomography, Magnetic resonance imaging and examination under anaesthetic. A tumour, node, metastasis (TNM) system was used. All patients subsequently underwent additional whole-body ¹8FDG PETCT scanning. Management was planned accordingly, blinded to ¹8FDG PETCT findings, at a multidisciplinary meeting, and reviewed again following disclosure of PETCT results. RESULTS: Forty patients (24 men), with a median age of 57 years (range 38-87 years), were prospectively recruited. All primary tumours were ¹8FDG avid. PETCT did not alter the T stage but did result in disease upstaging (N and M stages). Management was altered in five (12.5%) patients: one patient was identified to have an isolated distant metastasis, and four patients had ¹8FDG-avid lymph nodes not otherwise detected, all of which were tumour-positive on fine needle aspiration cytology/biopsy. CONCLUSION: PETCT upstages anal SCC and influences subsequent management. PETCT should be considered in the staging of anal SCC, although the definitive benefit of such a strategy requires further evaluation.

Incisional hernia rates following laparoscopic colorectal resection.

INTRODUCTION: In published series with satisfactory follow-up incisional hernia rates following laparotomy vary between 4 and 18%, with up to 75% developing within two years of operation. This therefore represents the commonest complication following open abdominal surgery and a substantial added workload for the colorectal/general surgeon. AIM: To prospectively review incisional hernia rates in patients undergoing laparoscopic colorectal resection in a single centre. METHODS: All laparoscopic wounds were closed in identical fashion to open closure technique, utilising 0-monofilament, polyglyconate and a mass closure technique, followed by a subcuticular, polyglactin-910 suture for skin closure. All patients were subsequently examined in an outpatient setting by a senior surgeon independent to the original procedure. RESULTS: 167 consecutive patients undergoing laparoscopic colorectal resections (94M:73F; median age 68 years) were included. Median incision length for specimen extraction was 6 cm (range 3-11 cm) and patients were followed-up for a median of 36 months (range 24-77 months). Twelve (7%) patients developed an incisional hernia (ten in specimen extraction wounds and two in port-site wounds), ten of whom underwent successful laparoscopic repairs. Of the remaining patients, one remains symptomatic and awaits repair, and one is asymptomatic and unfit for surgery. CONCLUSIONS: The well-documented advantages of laparoscopic surgery include reduced hospital stay, early return to activity, decreased analgesic requirements and improved cosmesis. However, the results of this study suggest that incisional hernia rates are not decreased by laparoscopic surgery, although the hernias may be smaller and more amenable to repair by laparoscopic approaches.

Splenic injury following colonoscopy--an underdiagnosed, but soon to increase, phenomenon?

INTRODUCTION: We present a case of splenic rupture in a 71-year-old woman admitted 6 days following a diagnostic colonoscopy. She underwent an open splenectomy and made a delayed, but complete, recovery. We proceeded to perform a retrospective review of all relevant literature to assess the frequency of similar post-colonoscopy complications. MATERIALS AND METHODS: Using relevant keywords, we identified 63 further PubMed reports of splenic injury associated with colonoscopy that were reported in English. FINDINGS: We have described only the fourth report of splenic injury secondary to colonoscopy from a UK centre. Literature review reveals a mean age of 63 years and a female preponderance for this complication. Most patients present on the day of their colonoscopy with abdominal pain, anaemia, elevated white cell count and Kehr's sign. CT is the investigation of choice and splenectomy the definitive management of choice. Most patients make a routine recovery, with mortality rates of approximately 8%. There is likely to be an under-reporting of this complication from UK-based centres, with the majority of reports originating from Europe and US. This points to a possible under-diagnosis or under-recognition of this potentially fatal complication. The incidence of such post-colonoscopic complications may increase with the forthcoming introduction of the National Bowel Cancer Screening Programme.

The management of multi-site, bleeding, visceral artery pseudoaneurysms, secondary to necrotising pancreatitis.

We present the case of a 45-year-old man, who presented to his local casualty department with severe epigastric pain following an alcohol binge, and was subsequently diagnosed with acute pancreatitis. Pancreatic necrosis with multiple collections ensued, necessitating transfer to an intensive care unit (ITU) in a tertiary hepatopancreaticobiliary centre. Initially, the patient appeared to slowly improve and was discharged to the ward, albeit following a prolonged ITU admission. However, during his subsequent recovery, he suffered multiple episodes of haematemesis and melaena associated with haemodynamic instability and requiring repeat admission to the ITU. Computerised tomographic angiography, followed by visceral angiography, was used to confirm the diagnosis of multisite visceral artery pseudoaneurysms, secondary to severe, necrotising pancreatitis. Pseudoaneurysms of the splenic, left colic and gastroduodenal arteries were sequentially, and successfully, radiologically embolised over a period of 9 days. Subsequent sequelae of radiological embolisation included a clinically insignificant splenic infarct, and a left colonic infarction associated with subsequent enterocutaneous fistula formation. The patient made a prolonged, but successful, recovery and was discharged from hospital after 260 days as an in-patient. This case illustrates the rare complication of three separate pseudoaneurysms, secondary to acute pancreatitis, successfully managed radiologically in the same patient. This case also highlights the necessity for multidisciplinary involvement in the management of pseudoaneurysms, an approach that is often most successfully achieved in a tertiary setting.

The effect of preoperative weight loss and body mass index on postoperative outcome in patients with esophagogastric carcinoma.

Studies have shown that weight loss is associated with adverse outcomes in all treatment modalities for esophagogastric carcinoma. Because of the increased prevalence of obesity and the effectiveness of perioperative nutrition, a number of patients are now obese or have normal body mass index (BMI) at the time of treatment. We investigated the relationship between weight loss, BMI, and outcome of surgery for patients with esophagogastric carcinoma. Data were collected over a 38-month period for all patients diagnosed with operable esophagogastric cancer at two UK centers. All patients underwent resection by a single Consultant Upper Gastrointestinal Surgeon and the use of perioperative jejunal feeding was universal. Ninety-three patients (57 male) underwent esophagogastric resection; 48 had no preoperative weight loss (34 with a BMI > 25 and 14 with a BMI < 25). Forty-five patients had preoperative weight loss (20 with BMI > 25 and 25 with BMI < 25). There was no significant difference in complication rates, median hospital stay, or mortality between the four groups. A significantly higher number of patients displaying preoperative weight loss were found to have stage III disease, but difference in survival of up to 3 years did not reach statistical significance on multivariate analysis. Preoperative weight loss and low BMI did not significantly influence the complication rate, perioperative mortality rate, length of hospital stay, or short-term prognosis. We conclude that preoperative weight loss can not be reliably used as an independent predictor of poor outcome in patients undergoing surgery for esophagogastric carcinoma. However, patients with preoperative weight loss and low BMI are more likely to have advanced disease.

Community forensic psychiatry: restoring some sanity to forensic psychiatric rehabilitation.

OBJECTIVE: To review clinical and legal paradigms of community forensic mental health care, with specific focus on New Zealand, and to develop a clinically based set of guiding principles for service development in this area. METHOD: The general principles of rehabilitating mentally disordered offenders, and assertive community care programmes were reviewed and applied to the law and policy in a New Zealand forensic mental health setting. RESULTS: There is a need to develop comprehensive community treatment programmes for mentally disordered offenders. The limited available research supports assertive community treatment models, with specialist forensic input. Ten clinically based principles of care provision important to forensic mental health assertive community treatment were developed. CONCLUSION: Deinstitutionalization in forensic psychiatry lags behind the rest of psychiatry, but can only occur with well-supported systems in place to assess and manage risk in the community setting. The development of community-based forensic rehabilitation services in conjunction with general mental health is indicated.

Evidence-based rehabilitation in forensic psychiatry.

BACKGROUND: The extent to which forensic psychiatric rehabilitation alters an individual's level of risk is unclear. AIMS: To highlight some essential features of a forensic psychiatric rehabilitation system, and to discuss risk assessment in this context to create a conceptual framework for risk research and practice. METHOD: The applicability of risk assessment instruments to forensic psychiatric rehabilitation was examined. Core processes and elements considered essential in this type of rehabilitative work were reviewed. RESULTS: Current risk research has limited application to rehabilitation. Future research aimed at analysing forensic psychiatric rehabilitation will be hampered by the complexity of the treatment systems and the number of methodological issues relevant to this type of research. CONCLUSIONS: Novel research approaches are suggested to analyse further the risk factors and processes important in forensic psychiatric rehabilitation.