Systematic review and meta-analysis of laparoscopic Nissen fundoplication with or without division of the short gastric vessels.

BACKGROUND: The aim of this meta-analysis was to provide a pooled analysis of individual trials comparing clinical outcome following laparoscopic Nissen fundoplication with or without division of the short gastric vessels (SGVs). METHODS: Primary outcome measures were the requirement for reoperation, and the presence of postoperative gastro-oesophageal reflux and postoperative dysphagia. Secondary outcome measures were duration of operation, length of hospital stay, postoperative complications (within 30 days of surgery), postoperative gas bloat syndrome, lower oesophageal sphincter resting pressure and DeMeester score. Pooled odds ratios were calculated for categorical outcomes, and weighted mean differences for secondary continuous outcomes, using random-effects models for meta-analysis. RESULTS: Five randomized trials were included in the analysis. There was no statistically significant effect on the requirement for reoperation, or presence of postoperative dysphagia or reflux. SGV division was associated with a longer duration of operation and a reduced postoperative lower oesophageal sphincter pressure. There was no statistically significant difference in length of hospital stay, postoperative complications, postoperative gas bloat syndrome or DeMeester score. CONCLUSION: This meta-analysis has demonstrated that clinical outcome following laparoscopic Nissen fundoplication appears to be similar regardless of whether the short gastric vessels are divided. However, it is not possible to exclude many potentially important clinical differences and further studies are needed.

Importance of routine cavity sampling in breast conservation surgery.

BACKGROUND: The role of cavity biopsy (CB) at the time of wide local excision (WLE) for primary breast cancer has not been evaluated fully. This study compared four groups of patients to determine the significance of margins and CB histology on tumour characteristics and outcome. METHODS: This was a retrospective study of patients undergoing WLE and CB in one institution over 21 years. Demographic data, tumour characteristics and survival information were obtained. Four subgroups of patients were compared according to their margin and cavity status (positive or negative). RESULTS: A total of 957 patients had WLE. The median 10-year survival was 85.6 per cent and breast cancer-specific survival was 92.4 per cent. Tumour size, grade, node and oestrogen receptor status were independent predictors of survival. There was poor concordance between positivity of resection margins and CB (32.0 per cent); a negative margin carried a 10.8 per cent risk of demonstrable residual disease. A positive CB, but not a positive margin, was associated with reduced overall survival and breast cancer-specific survival. CONCLUSION: Cavity status was more significant with regard to survival than margin status. CB is important in identifying residual and multifocal disease, as margin and cavity positivity are often not concordant.

Mycotic aneurysm of the posterior tibial artery -- a rare complication of bacterial endocarditis: a case report.

INTRODUCTION: Distal arterial embolisation and subsequent aneurysm formation are rare occurrences and most are secondary to trauma. We have found no case reports that describe posterior tibial aneurysm formation secondary to bacterial endocarditis. CASE PRESENTATION: We report the case of a 47-year-old Caucasian man who, 2 years after an episode of subacute bacterial endocarditis, presented with signs and symptoms consistent with posterior tibial aneurysm formation. CONCLUSION: Posterior tibial aneurysm formation is a rare occurrence, most commonly occurring after trauma and, although other causes have been described, to our knowledge, endocarditis has not been implicated before, and as such should therefore be borne in mind when dealing with cases where no obvious aetiology is evident.

Preoperative chemotherapy and the outcome of liver resection for colorectal metastases.

BACKGROUND: Neoadjuvant systemic chemotherapy is being increasingly used prior to liver resection for colorectal metastases. Oxaliplatin has been implicated in causing structural changes to the liver parenchyma, and such changes may increase the morbidity and mortality of surgery. PATIENTS AND METHODS: A retrospective study was undertaken of 101 consecutive patients who had undergone liver resection for colorectal metastases in two HPB centers. Preoperative demographic and premorbid data were gathered along with liver function tests and tumor markers. A subjective assessment of the surgical procedure was noted, and in-hospital morbidity and mortality were calculated. The effect of preoperative chemotherapy on short-term and long-term outcome was analyzed, and actuarial 1 and 3 year survival was determined. RESULTS: Patients who received neoadjuvant chemotherapy had a higher number of metastases (median 2, range 1-8 versus median 1, range 1-5; P = 0.019) and more had synchronous tumors (24 patients versus 8; P < 0.001). Overall morbidity was 37% and hospital mortality was 3.9%. Operative and in-hospital outcome was not influenced by chemotherapy. Long-term survival was worse in patients who had received preoperative chemotherapy (actuarial 3-year survival 62% versus 80%; P = 0.04). CONCLUSIONS: This study shows no evidence that neoadjuvant chemotherapy, and in particular oxaliplatin, increases the risk associated with liver resection for colorectal metastases. Long-term outcome is reduced in patients receiving preoperative chemotherapy, although they have more advanced disease.