Gastric outlet obstruction secondary to a wandering spleen: systematic review and surgical management of a case.

INTRODUCTION: A wandering spleen occurs when laxity or absence of the suspensory ligaments allows migration throughout the abdomen. Gastric outlet obstruction resulting from this abnormality is rare. We present a systematic literature search and a case that was managed successfully with surgical intervention at our centre. METHODS: A systematic search of the PubMed, Embase™, Medline® and Google Scholar™ databases was carried out employing the combined search terms "gastric outlet obstruction" AND "wandering spleen". Six results were included for final analysis. RESULTS: All six search results described a single case each. Patients underwent surgical management (open or laparoscopic) after initial investigation utilising a range of modalities. There were no mortalities reported at 90 days. The single case we present was complicated by gastric perforation; the patient made a successful recovery following open splenopexy and stapled wedge resection of the stomach. CONCLUSIONS: A wandering spleen is a rare diagnosis and there are only six reported cases of gastric outlet obstruction secondary to a wandering spleen in the literature. None report associated gastric perforation. There are a variety of presenting symptoms, intraoperative findings and operative techniques used to address the gastrosplenic abnormality. The case reported by our centre adds to this limited evidence base and demonstrates a successful outcome from definitive surgical management. We highlight the need to seek early gastro-oesophageal expertise if any gastric pathology is found together with anatomical abnormality of the spleen.

Herpes simplex oesophagitis leading to perforation and mediastinal collection: a case report and review of literature.

Herpes simplex oesophagitis is rare, especially in immunocompetent patients. A 78-year-old man presented with sepsis on the background of several months of retrosternal chest pain and fatigue. Computed tomography of the chest abdomen and pelvis revealed a large mediastinal collection and an oesophago-gastro-duodenoscopy demonstrated a healed mucosal scar from a spontaneously healed perforation. The collection was successfully drained with an ultrasound-guided drain and the patient made a full recovery. Spontaneous oesophageal perforation from herpes simplex oesophagitis has been reported five times in the literature, with only two occurrences in immunocompetent individuals.

Systematic review on reporting of components and outcomes in randomized clinical trials of paraoesophageal hernia mesh repair.

BACKGROUND: Surgical interventions, such as paraoesophageal hernia (POH) repair, are complex with multiple components that require consideration in the reporting of clinical trials. Many aspects of POH repair, including mesh hiatal reinforcement and fundoplication type, are contentious. This review summarizes the reporting of components and outcomes in RCTs of POH repair. METHODS: Systematic searches identified RCTs of POH repair published from 1995 to 2020. The patient selection criteria for RCT involvement were noted. The components of the surgical interventions in these RCTs were recorded using the CONSORT guidelines for non-pharmacological treatments, Template for Intervention Description and Replication (TIDieR) and Blencowe frameworks. The outcomes were summarized and definitions sought for critical variables, including recurrence. RESULTS: Of 1918 abstracts and 21 screened full-text articles, 12 full papers reporting on six RCTs were included in the review. The patient selection criteria and definitions of POH between trials varied considerably. Although some description of trial interventions was provided in all RCTs, this varied in depth and detail. Four RCTs described efforts to standardize the trial intervention. Outcomes were reported inconsistently, were rarely defined fully, and overall trial conclusions varied during follow-up. CONCLUSION: This lack of detail on the surgical intervention in POH repair RCTs prevents full understanding of what exact procedure was evaluated and how it should be delivered in clinical practice to gain the desired treatment effects. Improved focus on the definitions, descriptions and reporting of surgical interventions in POH repair is required for better future RCTs.

Acute Budd-Chiari syndrome caused by inferior vena cava compression from a congenital diaphragmatic hernia.

Acute Budd-Chiari syndrome is a rare condition characterised by obstruction of hepatic venous outflow. We describe the case of a 52-year-old man, with a congenital Morgagni diaphragmatic hernia, who presented with acute onset abdominal pain, shortness of breath, lactic acidosis, hyperbilirubinaemia and transaminasaemia. Computed tomography revealed strangulation of the diaphragmatic hernia and extrinsic compression of the inferior vena cava from the herniated viscera. Emergency surgery was carried out to repair the hernia with a biosynthetic mesh, with complete resolution of the Budd-Chiari syndrome.

Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis.

Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo-peritoneum (30.6%), capno/pneumo-thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post-POEM, respectively. Symptom improvement was demonstrated with a pre- and post-POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre- and post-POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14-16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.

Risk of bleeding and adverse outcomes predicted by thromboelastography platelet mapping in patients taking clopidogrel within 7 days of non-cardiac surgery.

BACKGROUND: Patients often fail to stop clopidogrel appropriately before non-cardiac surgery. Thromboelastography platelet mapping (TEG-PM) can be used to measure the percentage adenosine 5'-diphosphate platelet receptor inhibition (ADP-PRI) by clopidogrel in these patients. METHODS: This prospective case-control study investigated the risk of bleeding in patients who had taken clopidogrel within 7 days of scheduled operation. Patients underwent TEG-PM to stratify their bleeding risk. Low-risk (ADP-PRI below 30 per cent) and urgent priority high-risk (ADP-PRI 30 per cent or more) patients proceeded to surgery. The outcomes of these patients were compared with those of matched controls. Regression analysis, with bootstrapping validation, was used to identify independent risk factors for bleeding and an optimal cut-off value of ADP-PRI for cancellation of surgery. RESULTS: From May 2008 to October 2013, 182 patients failed to discontinue clopidogrel. No correlation was observed between duration of clopidogrel omission and percentage ADP-PRI; 112 low-risk and 19 high-risk patients proceeded to surgery. High-risk patients had significantly greater intraoperative packed red blood cell (PRBC) transfusion in comparison with their matched controls, and a strong positive correlation between percentage ADP-PRI and units of intraoperative PRBCs transfused (r = 0·749, 95 per cent confidence interval (c.i.) 0·410 to 0·940; P < 0·001). Percentage ADP-PRI was the only independent risk factor for intraoperative PRBC transfusion (odds ratio 1·07, 95 per cent c.i. 1·02 to 1·13; P = 0·005). CONCLUSION: An objective measure of platelet inhibition with TEG-PM, using an ADP-PRI cut-off of 34 per cent, can be used to prevent unnecessary cancellations, while minimizing patient risk.

Discrimination of lymph node metastases using desorption electrospray ionisation-mass spectrometry imaging.

Desorption electrospray ionisation mass spectrometry imaging (DESI-MSI) has been used for the identification of cancer within lymph nodes with accurate spatial distribution in comparison to gold standard matched immuno-histopathological images. The metabolic profile of the cancerous lymph nodes was similar to that of the primary tumour site.

Metabolomic profiling of oesophago-gastric cancer: a systematic review.

AIMS: This review aims to identify metabolomic biomarkers of oesophago-gastric (OG) cancer in human biological samples, and to discuss the dominant metabolic pathways associated with the observed changes. METHODS: A systematic review of the literature, up to and including 9th November 2012, was conducted for experimental studies investigating the metabolomic profile of human biological samples from patients with OG cancer compared to a control group. Inclusion criteria for analytical platforms were mass spectrometry or nuclear magnetic resonance spectroscopy. The QUADAS-2 tool was used to assess the quality of the included studies. RESULTS: Twenty studies met the inclusion criteria and samples utilised for metabolomic analysis included tissue (n = 11), serum (n = 8), urine (n = 1) and gastric content (n = 1). Several metabolites of glycolysis, the tricarboxylic acid cycle, anaerobic respiration and protein/lipid metabolism were found to be significantly different between cancer and control samples. Lactate and fumurate were the most commonly recognised biomarkers of OG cancer related to cellular respiration. Valine, glutamine and glutamate were the most commonly identified amino acid biomarkers. Products of lipid metabolism including saturated and un-saturated free fatty acids, ketones and aldehydes and triacylglycerides were also identified as biomarkers of OG cancer. Unclear risk of bias for patient selection was reported for the majority of studies due to the lack of clarity regarding patient recruitment. CONCLUSION: The application of metabolomics for biomarker detection in OG cancer presents new opportunities for the purposes of screening and therapeutic monitoring. Future studies should provide clear details of patient selection and develop metabolite assays suitable for progress beyond phase 1 pre-clinical exploratory studies.

Ultrasound-guided foam sclerotherapy within a rolling treatment programme is an effective low-cost treatment for superficial venous insufficiency.

AIMS: To review the results and cost of a rolling ultrasound-guided foam sclerotherapy (UGFS) treatment programme for patients with chronic superficial venous insufficiency. METHOD: A prospective study of a rolling treatment programme where patients were offered unlimited follow-up at intervals of 6-8 weeks and further (top up) UGFS when necessary, until occlusion criteria were met. RESULTS: A total of 213 lower limbs with complete follow-up were included in the study. Median (range) age was 57 (16-94) years, maximum diameter of varicose vein was 10 (3-18) mm, C of CEAP (clinical, aetiological, anatomical and pathological elements) was 4 (2-6), number of treatment sessions was one (1-4) and follow-up was three (1.5-33) months. Satisfactory occlusion could not be achieved in nine (4%) limbs. The ratio of odds (95% CI) for requiring more than one treatment session was 3.58 (1.46-8.77), P = 0.002 for great saphenous varicosity and 2.11 (1.13-3.94), P = 0.015 for age 50 or more. There were 20 (9.3%) immediate and 63 (29.5%) delayed adverse effects. All were minor except for one cutaneous nerve injury, one pulmonary embolism and one infected haematoma. The ratio for odds (95% CI) for post-treatment skin discolouration was 2.59 (1.14-5.87), P = 0.017 for women and 1.32 (1.02-1.71), P = 0.032 for increasing sclerosant volume used. Service line costing per completed treatment episode was £115.22 (€130.07, $188.60). CONCLUSION: UGFS in a rolling treatment programme is safe and can achieve high occlusion rates at a low cost. Patients above the age of 50 with great saphenous varicosity are likely to require more than one treatment session.

A case of obscure gastrointestinal bleeding in a teenager.

In this report, we discuss a case of obscure gastrointestinal bleeding (OGIB) in an 18-year-old man, where oesophagogastroduodenoscopy (OGD) and colonoscopy proved inconclusive in determining a source of bleeding. On day 14 of admission, a laparoscopy was performed, identifying a mass 2 feet from the ileocaecal junction. This was thought initially to be a Meckel's diverticulum and the patient underwent a laparotomy and a small bowel resection. Surprisingly, the histology revealed a benign gastrointestinal stromal tumour (GIST) of the ileum, rare in such a young person. Given the diagnostic delay, we propose a simple algorithm for the diagnostic management of a teenager presenting with a significant ongoing gastrointestinal bleed.