Laparoscopic fundoplication performed in community hospital settings: A protocol for systematic review.

BACKGROUND: Laparoscopic fundoplication (LF) is well-established as the surgical intervention of choice for management of refactory gastro-esophageal reflux disease. Much of its success lies in the reported benefits in symptom control outlined by the postoperative patient. It is unclear whether patient-reported outcomes differ according to the institution type providing care. This review aimed to address this knowledge gap by reviewing the available evidence examining patient-reported outcomes of LF in non-metropolitan centers. OBJECTIVES: To investigate patient-reported outcomes of LF performed in regional or community-based hospitals. DATA SOURCES: Four electronic databases, and citations of relevant articles. STUDY ELIGIBILITY CRITERIA: Only studies that separately reported patient-reported outcomes of LF performed in regional or community hospitals were included; papers deemed to be unclear about the type of facility in which LF surgeries were performed, or in which data from LF surgeries performed in regional/community hospitals was combined with data from major metropolitan hospitals, were excluded. STUDY APPRAISAL: Only studies that were graded as fair or good using Quality Assessment Tool for Observational Cohort and Cross-sectional studies were eligible for inclusion in this review. Seven studies were then eligible for inclusion, all of which were observational cohort studies with 6 of the studies reporting on a single intervention arm. RESULTS: Seven observational cohort studies were included in the review, with a combined total of 1071 patients who underwent LF at non-metropolitan centers. Of these, data was collected for 742 patients, yielding an overall response rate of 69.3%. All 7 studies assessed patients' post-operative outcomes through questionnaires that were based on a modified Likert scale or a similar tool. Overall patient satisfaction was high (86%) and a significant majority of patients stated they would recommend the procedure to others (93.3%). Post-operative prevalence of reflux and dysphagia compared favorably to rates generally reported in the literature (11.9% and 17.6% respectively). Further research is required to ascertain the safety of performing these procedures in non-metropolitan hospitals. CONCLUSION: Current evidence suggests that patient-reported outcomes are favorable for patients undergoing LF in community settings, and are broadly comparable to those undergoing LF in tertiary-level centers.

Successful non-operative management of a traumatic thyroid haematoma in a goitrous gland.

Traumatic haemorrhage of the thyroid is an uncommon injury, especially in patients without pre-existing thyroid disease. Goitrous glands have an increased risk of haemorrhage following trauma due to their increased size and vascularity. Traditionally, traumatic thyroid haematomas were indiscriminately managed with neck exploration. Over time, the role of the close observation in the management of these injuries was explored, and it became common for patients with traumatic haematomas in otherwise normal thyroid glands to be managed non-operatively if no signs of ongoing bleeding or airway compromise manifested. However, patients with known goitrous glands continued to undergo neck exploration and resection of the affected gland. Herein we discuss the case of a traumatic thyroid haematoma managed non-operatively in a patient with a goitrous gland and discuss its implications for the management of similar future cases.

Pancreatic leiomyosarcoma: a diagnostic challenge and literature review.

A 71-year-old woman was referred with abdominal pain and weight loss. An abdominal CT showed a 5-cm heterogeneous mass in the head of the pancreas with involvement of the superior mesenteric vein and artery. Her carcinoembryonic antigen (CEA) and CA 19-9 were normal. Two endoscopic ultrasound/fine needle aspirates (EUS/FNAs) of the mass diagnosed her with a mesenchymal tumour of myogenic origin but did not show features of malignancy. Frozen section analysis of laparoscopic core biopsies also failed to show malignant features, hence requiring an open biopsy which confirmed the diagnosis of pancreatic leiomyosarcoma (PLMS). She was eventually treated with radiotherapy. To our knowledge this is the only case in recent English literature of inoperable locally advanced PLMS that has required an open biopsy to formalise the diagnosis despite prior EUS FNAs. We include a review of the literature, highlighting the deficiencies of various biopsy techniques.

Necrotizing Fasciitis of the Breast: A Case Report and Literature Review.

A 51-year-old woman presented to our facility with an open wound in the left breast. This was associated with a hard, non-mobile, tender lesion palpable underneath. The wound contained central necrosis with surrounding purulent discharge and accompanying erythema. Following radical debridement of the breast down to the pectoralis fascia the patient had a vacuum-assisted closure (VAC) device dressing applied. Histological examination was consistent with necrotizing fasciitis of the breast.