Quality of life following repair of large hiatal hernia is not influenced by the use of mesh-Longer-term follow-up from a randomized trial.

INTRODUCTION: The use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial. METHODS: A prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes. RESULTS: 126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups. CONCLUSION: Surgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life. TRIAL REGISTRATION: This trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.

Writing Multiple Choice Questions-Has the Student Become the Master?

CONSTRUCT: We compared the quality of clinician-authored and student-authored multiple choice questions (MCQs) using a formative, mock examination of clinical knowledge for medical students. BACKGROUND: Multiple choice questions are a popular format used in medical programs of assessment. A challenge for educators is creating high-quality items efficiently. For expediency's sake, a standard practice is for faculties to repeat items in examinations from year to year. This study aims to compare the quality of student-authored with clinician-authored items as a potential source of new items to include in faculty item banks. APPROACH: We invited Year IV and V medical students at the University of Adelaide to participate in a mock examination. The participants first completed an online instructional module on strategies for answering and writing MCQs, then submitted one original MCQ each for potential inclusion in the mock examination. Two 180-item mock examinations, one for each year level, were constructed. Each consisted of 90 student-authored items and 90 clinician-authored items. Participants were blinded to the author of each item. Each item was analyzed for item difficulty and discrimination, number of item-writing flaws (IWFs) and non-functioning distractors (NFDs), and cognitive skill level (using a modified version of Bloom's taxonomy). FINDINGS: Eighty-nine and 91 students completed the Year IV and V examinations, respectively. Student-authored items, compared with clinician-authored items, tended to be written at both a lower cognitive skill and difficulty level. They contained a significantly higher rate of IWFs (2-3.5 times) and NFDs (1.18 times). However, they were equally or better discriminating items than clinician-authored items. CONCLUSIONS: Students can author MCQ items with comparable discrimination to clinician-authored items, despite being inferior in other parameters. Student-authored items may be considered a potential source of material for faculty item banks; however, several barriers exist to their use in a summative setting. The overall quality of items remains suboptimal, regardless of author. This highlights the need for ongoing faculty training in item writing.

Randomized Trial of Laparoscopic Nissen Versus Anterior 180 Degree Partial Fundoplication - Late Clinical Outcomes at 15 to 20 years.

OBJECTIVE: To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures. METHODS: One hundred seven participants were randomized to Nissen versus anterior 180-degree partial fundoplication. Fifteen to 20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0 to 10 analog scores and yes/no questions to determine reflux symptoms, side-effects, and satisfaction with surgery. RESULTS: After anterior fundoplication heartburn (mean score 3.2 vs 1.4, P = .001) and proton pump inhibitor use (41.7% vs 17.1%, P = .023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, P = .015), and better ability to belch (84.2% vs 65.9%, P = .030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, P = .444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision after anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision after Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1). CONCLUSIONS: At 15 to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control versus more side-effects after Nissen fundoplication.

Pharyngeal Pouch Surgery in Octo- and Nonagenarians is Safe and Effective: A Multicentre Comparative Cohort Study.

BACKGROUND: Surgery is the only effective treatment strategy for a symptomatic pharyngeal pouch. However, octo- and nonagenarians are often denied referral to a surgeon because of perceived increased risks. Here, we compare the outcomes of pharyngeal pouch surgery in octo- and nonagenarians with patients under 80 years-of-age and determine the factors which predict post-operative complications and improvement in swallowing. METHODS: Analysis of a prospectively maintained database of patients who underwent pharyngeal pouch surgery across seven hospitals over 15 years. RESULTS: In total, 113 patients (≥80 years-of-age: 27, <80 years-of-age: 86) underwent endoscopic or open pharyngeal pouch surgery. Despite more comorbidities and a longer hospital stay (median: one extra day), patients ≥80 years-of-age had comparable operative time, complication profile, intensive care admission, emergency reoperation, and revisional pouch surgery as their younger counterparts. Furthermore, the severity of complications was not significantly different between the two age cohorts. No surgical mortality was recorded. Multivariate analysis demonstrated that diverticulectomy combined with cricopharyngeal myotomy independently predicted higher rates of complications (OR: 4.53, 95% CI: 1.43-14.33, p = 0.010), but also greater symptomatic improvement (OR: 4.36, 95% CI: 1.50-12.67, p = 0.007). Importantly, a greater proportion of octo- and nonagenarians experienced improved swallowing than patients <80 years-of-age (96.3% vs. 74.4%, p = 0.013). Moreover, advanced age was not predictive of post-operative complications on multivariate analysis. CONCLUSIONS: Pharyngeal pouch surgery in octo- and nonagenarians is safe and effective. Surgical correction in this age group alleviates symptoms and improves quality-of-life for most patients. These patients should not be denied surgery on the basis of advanced age alone.

Five Year Follow-up of a Randomized Controlled Trial of Laparoscopic Repair of Very Large Hiatus Hernia With Sutures Versus Absorbable Versus Nonabsorbable Mesh.

OBJECTIVE: To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair. SUMMARY OF BACKGROUND DATA: Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair. METHODS: Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years. RESULTS: 126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh. CONCLUSIONS: No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

Acceptable outcomes after fundoplication-different views are held by patients, GPs, and surgeons.

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29-0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17-3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.

Choosing medical assessments: Does the multiple-choice question make the grade?

Background: The multiple-choice question (MCQ) has been shown to measure the same constructs as the short-answer question (SAQ), yet the use of the latter persists. The study aims to evaluate whether assessment using the MCQ alone provides the same outcomes as testing with the SAQ. Methods: A prospective study design was used. A total of 276 medical students participated in a mock examination consisting of forty MCQs paired to forty SAQs, each pair matched in cognitive skill level and content. Each SAQ was marked by three independent markers. The impact of item-writing flaws (IWFs) on examination outcome was also evaluated. Results: The intraclass correlation coefficient (ICC) was 0.75 for the year IV examinations and 0.68 for the year V examinations. MCQs were more prone to IWFs than SAQs, but the effect when present in the latter was greater. Removal of questions containing IWFs from the year V SAQ allowed 39% of students who would otherwise have failed to pass. Discussion: The MCQ can test higher order skills as effectively as the SAQ and can be used as a single format in written assessment provided quality items testing higher order cognitive skills are used. IWFs can have a critical role in determining pass/fail results.

Randomized Trial of Division Versus Nondivision of Short Gastric Vessels During Nissen Fundoplication: 20-Year Outcomes.

OBJECTIVE: To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up. BACKGROUND: Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division. METHODS: A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined. RESULTS: No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989). CONCLUSIONS: Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.

Outcome for Patients With Pathological Esophageal Acid Exposure After Laparoscopic Fundoplication.

OBJECTIVE: The aim of the current study was to assess symptomatic outcome and need for surgical reintervention for patients identified with pathological esophageal acid exposure by routine postoperative 24-hour pH-monitoring. BACKGROUND: Although laparoscopic fundoplication is associated with excellent short- and midterm results, recurrent symptoms pose an important challenge. Postoperative pH-monitoring is considered the "gold standard" for diagnosing recurrent GERD and frequently used for routine postoperative follow up. METHODS: Analysis of prospectively collected data from patients who underwent laparoscopic fundoplication between April 1994 and June 2015 and underwent routine postoperative 24-hour pH-monitoring was performed. Symptomatic outcome and need for surgical reintervention up to 5 years was compared between patients with pathological and physiological postoperative esophageal acid exposure. Primary endpoints were heartburn score and need for surgical reintervention for recurrent reflux. RESULTS: A total of 309 patients in whom routine postoperative 24-hour pH-monitoring was performed were included. Pathological acid exposure was present in 33 patients (11%) compared with 276 patients (89%) with physiological acid exposure. During 5-year follow up, there were no differences in heartburn, dysphagia, or satisfaction scores. Eighteen percent of all patients with abnormal postoperative pH-studies underwent redo fundoplication during 5-year follow up. CONCLUSIONS: Pathological acid exposure demonstrated by routine postoperative pH-monitoring was not associated with worse symptomatic outcome in terms of reflux control and satisfaction. A possible explanation for this finding is that laparoscopic fundoplication reduces the patients' ability to perceive reflux. This underlines the importance of assessing the association between symptomatic outcome and esophageal function tests in determining outcome of antireflux surgery.

Clinical Decision-Making: Observing the Smartphone User An Observational Study in Predicting Acute Surgical Patients' Suitability for Discharge.

INTRODUCTION: An accurate and rapid assessment of an acutely unwell patient's clinical status is paramount for the physician. There is an increasing trend to rely on investigations and results to inform a clinician of a patient's clinical status, with the subtleties of clinical observation often ignored. The aim of this study was to determine if a patient's use of a smartphone during the initial clinical assessment by a surgical consultant could be used as a surrogate marker for patient well-being, represented as their suitability for sameday discharge. METHODS: This was a prospective observational study performed over 2 periods at a tertiary hospital in South Australia. All patients admitted by junior surgical doctors from the emergency department to the acute surgical unit were eligible for inclusion. Upon consultant review, their status as a smartphone user was recorded in addition to their duration of hospital stay and basic demographic data. All patients and all but 1 of the consultants were blinded to the trial. RESULTS: Two hundred and twenty-one patients were eligible for inclusion. Of these patients, 11.3% were observed to be using a smartphone and 23.5% of patients were discharged home on day 1. Those who were observed to be using a smartphone were 5.29 times more likely to be discharged home on day 1 and were less likely to be subsequently readmitted. CONCLUSIONS: The addition of the smartphone sign to a surgeon's clinical acumen can provide yet another tool in aiding the decision for suitability for discharge.

Examining the impact of specific types of item-writing flaws on student performance and psychometric properties of the multiple choice question.

This article was migrated. The article was marked as recommended. Background: Item-writing flaws (IWFs) are common in multiple choice questions (MCQs) despite item-writing guidelines. Previous studies have shown that IWFs impact validity as observed through student performance, item difficulty, and discrimination. Most previous studies have examined IWFs collectively and have shown that they have a diverse impact. The aim of the study was to determine if the effects of individual types of IWFs are systematic and predictable. Method: A cross-over study design was used. 100 pairs of MCQ items (with and without an IWF) were constructed to test 10 types of IWFs. Medical students were invited to participate in a mock examination. Paper A consisted of 50 flawed followed by 50 unflawed items. Paper B consisted of 50 unflawed followed by 50 flawed items. The effect of each of the IWFs on mean item scores, item difficulty and discrimination were examined. Results: The hypothesised effect of IWFs on mean item scores was confirmed in only 4 out of 10 cases. ' Longest choice is correct', 'Clues to the right answer (Eponymous terms)' and ' Implausible distractors' positively impacted, while 'Central idea in choices rather than stem' negatively impacted mean item scores. Other flaws had either the opposite or no statistically significant effect. IWFs did not impact item difficulty or discrimination. Conclusion: The effect of IWFs is neither systematic nor predictable. Unpredictability in assessment produces error and thus loss of validity. Therefore, IWFs should be avoided. Faculties should be encouraged to invest in item-writing workshops in order to improve MCQs. However, the cost of doing so should be carefully weighed against the benefits of developing programmes of assessment.

Follow-Up Practices of Surgeons and Medical Oncologists in Australia and New Zealand Following Resection of Esophagogastric Cancers.

PURPOSE: Follow-up practices for patients who have undergone surgical resection of esophagogastric malignancies are variable and poorly documented. To better understand practice, a questionnaire was used to survey surgeons and medical oncologists to determine whether any consensus exists. METHODS: An opt-in online questionnaire was sent to esophagogastric surgeons and medical oncologists via the membership lists for the Australian and New Zealand Gastric and Oesophageal Surgery Association (ANZGOSA), the Australian Gastro-Intestinal Trials Groups (AGITG), and the Medical Oncology Group of Australia (MOGA). The questionnaire proposed five clinical scenarios and provided a range of follow-up options for each scenario. Clinicians were asked to indicate which best matched their clinical practice. RESULTS: Most clinicians follow patients for at least 3-5 years following resection of gastric or esophageal cancer. In total, 52% perform routine surveillance imaging, with individual scenarios not altering this. Tumor markers are infrequently used. Endoscopy and routine blood tests are used by around half the respondents. CONCLUSION: There was little consensus about the use of investigations to monitor patients following esophagogastric cancer surgery. Choices do not follow guidelines or evidence. The identified patterns of postoperative surveillance practice appear not to be evidence based, and generally do not match recently published Australian guidelines.

Long-term Efficacy of Laparoscopic Antireflux Surgery on Regression of Barrett's Esophagus Using BRAVO Wireless pH Monitoring: A Prospective Clinical Cohort Study.

OBJECTIVE: To assess the long-term efficacy of antireflux surgery on Barrett's esophagus (BE) using BRAVO wireless pH monitoring. BACKGROUND: BE is associated with chronic gastroesophageal reflux and esophageal cancer. Till date, studies have failed to demonstrate that preventing gastroesophageal reflux with antireflux surgery halts the progression of BE, often because of difficulties in objectively proving an effective antireflux barrier. METHODS: Since 1991, all patients undergoing antireflux surgery across 2 hospital sites have been followed in a prospective database. Patients with BE and at least 5 years follow up after antireflux surgery were identified. All patients completed a clinical outcome questionnaire and underwent endoscopic assessment and histological evaluation of their BE. Fourty-eight hours pH monitoring was then performed with the wireless BRAVO system. RESULTS: A total of 50 patients (40 males:10 females) were included in the study, with an average follow up of 11.9 years. Approximately, 92% (46/50) reported their outcome of surgery as "excellent" or "good" and 86% (43/50) reported "none" or "mild" symptoms. Histological regression of BE was seen in 41% (20/49). Lower esophageal acid exposure (percentage time pH < 4) was significantly greater in those with no pathological regression (P = 0.008). Moreover, 64% (32/50) showed endoscopic reduction in the length of BE. Acid exposure was also significantly less in the group showing endoscopic reduction of BE (%time pH < 4, 0.2 vs 3.6, P = 0.007). CONCLUSIONS: Antireflux surgery is safe and effective in patients with Barrett's esophagus. An intact fundoplication, as assessed with BRAVO wireless pH monitoring, suggests that antireflux surgery may halt the progression of Barrett's esophagus, and this might reduce the risk of cancer development.

Update in achalasia: what the surgeon needs to know.

Achalasia is a motility disorder encountered by surgeons during the investigation and treatment of dysphagia. Recent advances in manometry technology, a widely accepted new classification system and a new treatment rapidly gaining international acceptance, have changed the working knowledge required to successfully manage patients with achalasia. We review the Chicago classification subtypes of achalasia with type II achalasia being a predictor of success and type III achalasia a predictor of treatment failure. We review per-oral endoscopic myotomy as an emerging treatment option and its potential for improving the treatment of type III achalasia.

Improving care for patients with oesophageal and gastric cancer: impact of a statewide multidisciplinary team.

BACKGROUND: To standardize management of upper gastrointestinal (GI) cancer in South Australia, a statewide video linked multidisciplinary team (MDT) meeting was established in late 2009. Although cancer MDTs are recognized as a standard of care, it is important to audit their impact. METHODS: A retrospective audit of MDT outcomes and recommendations for patients reviewed by the upper GI MDT between 1 January 2010 and 31 December 2011 was undertaken. The proportion of patients with new upper GI malignancies reviewed and the proportion reviewed within 2 weeks of diagnosis were determined. Recommendations from the MDT meetings regarding treatment intent, management, investigations and trial participation were audited. RESULTS: From 2010 to 2011, the proportion of newly diagnosed upper GI malignancies in South Australia reviewed by the MDT increased from 43.2% to 54.3%. More oesophageal than gastric cancer cases were reviewed by the MDT. The proportion of patients reviewed within 2 weeks of diagnosis increased from 20% to 50%. The proportion of patients referred for neoadjuvant or definitive chemoradiotherapy increased from 2010 to 2011. Fifty per cent of all patients reviewed were recommended to have further investigations. Recommendations for clinical trial participation increased from 0% in 2010 to 11% in 2011. CONCLUSION: A statewide upper GI cancer MDT is feasible. Implementation of the MDT was followed by an increase in the number of patients reviewed and the proportion reviewed within 2 weeks of diagnosis. Greater awareness of the MDT and access to it may be required to continue to increase the proportion of cancers reviewed.

Retrospective analysis of surgery and trans-arterial embolization for major non-variceal upper gastrointestinal bleeding.

BACKGROUND: With proton pump inhibitors and current sophisticated endoscopic techniques, the number of patients requiring surgical intervention for upper gastrointestinal bleeding has decreased considerably while trans-arterial embolization is being used more often. There are few direct comparisons between the effectiveness of surgery and embolization. METHODS: A retrospective study of patients from two Australian teaching hospitals who had surgery or trans-arterial embolization (n = 103) for severe upper gastrointestinal haemorrhage between 2004 and 2012 was carried out. Patient demographics, co-morbidities, disease pathology, length of stay, complications, and overall clinical outcome and mortality were compared. RESULTS: There were 65 men and 38 women. The median age was 70 (range 36-95) years. Patients requiring emergency surgical intervention (n = 79) or trans-arterial embolization (n = 24) were compared. The rate of re-bleeding after embolization (42%) was significantly higher compared with the surgery group (19%) (P = 0.02). The requirement for further intervention (either surgery or embolization) was also higher in the embolization group (33%) compared with the surgery group (13%) (P = 0.03). There was no statistical difference in mortality between the embolization group (5/24, 20.8%) and the surgical group (13/79, 16.5%) (P = 0.75). CONCLUSION: Emergency surgery and embolization are required in 2.6% of patients with upper gastrointestinal bleeding. Both techniques have high mortalities reflecting the age, co-morbidities and severity of bleeding in this patient group.

Tracheo-oesophageal fistula after palliative treatment of oesophageal cancer.

We present a case of an 86-year-old male who presented with severe pneumonia in the context of having undergone radiotherapy and then an oesophageal stent insertion for palliation of oesophageal cancer. He was diagnosed with a tracheo-oesophageal fistula (TOF) which was successfully managed by deploying a second stent within the first stent.