Patient-reported outcomes of laparoscopic magnetic sphincter augmentation for gastro-oesophageal reflux disease.

INTRODUCTION: Gastro-oesophageal reflux disease (GORD) is a chronic progressive disease, associated with substantial clinical and economic burden. Proton pump inhibitors (PPIs) are considered first-line treatment; however, there are concerns around the long-term impact of their usage. Surgical treatment with Nissen fundoplication can be considered but, because of the potential side effects, few patients undergo surgery and there remains a substantial therapeutic gap within the current treatment pathway. Laparoscopic magnetic sphincter augmentation (MSA) using the LINX® device is an alternative surgical approach. METHODS: The objective of this study was to investigate patient-reported outcomes following laparoscopic MSA surgery using the LINX® device in a UK setting. A retrospective questionnaire obtained data regarding postoperative symptoms, medication use and patient satisfaction. RESULTS: Out of 131 patients surveyed, 97 responses were received, with a minimum follow-up time of 1 year. In those who reported heartburn and regurgitation preoperatively, improvement was reported in 93% (84/90) and 90% (86/96) of patients, respectively. Eighty-eight per cent (73/83) of patients were able to completely stop or reduce their medication by at least 75%. Seventy-seven per cent (73/95) of patients were "very satisfied" or "satisfied". CONCLUSIONS: This study is the first to present patient-reported outcomes of MSA using the LINX® device for patients with GORD in the UK. It demonstrates that the device has favourable outcomes and could effectively bridge the current therapeutic gap that exists between PPI medication and Nissen fundoplication.

Gastric ulceration causing thoracic spondylodiscitis: a first case of a rare complication post oesophagectomy.

We report the case of an 84-year-old male, who presented with septicaemia, abdominal and back pain. The patient had a background of oesophageal carcinoma and had undergone previous oesophagectomy and gastric pull-up operation 10 years ago. A computerised topography scan demonstrated a probable gastro-vertebral communication with a destructive process at the T8/T9 vertebral level. Further evaluation with MRI clearly showed the tract between the two structures and confirmed the diagnosis of spondylodiscitis at the adjacent spinal level. The patient was resuscitated, treated with intravenous antibiotics and kept nil by mouth. A subsequent gastroscopy demonstrated an eroding gastric ulcer at the enteric opening of the tract between the tubal stomach and the spinal column. The diagnosis was discussed with the patient, his family and the surgical multidisciplinary team. Given the extent of disease and his multiple medical co-morbidities, the decision was made for conservative management and symptom control. This is the first case of a gastro-vertebral communication causing spondylodiscitis to be described in the literature.

A novel technique for modified onlay incisional hernia repair with mesh incorporation into the fascial defect: a method for addressing suture line failure.

PURPOSE: Biological mechanisms such as abnormal wound healing and impaired scar formation are important aetiological factors in the development of abdominal wall hernias. Standard onlay repair often involves suture closure of the fascial defect with placement of the mesh over this closed defect. This has the disadvantage that suture line failure may occur early in the healing process and predispose to recurrence. Our technique aims to overcome this by incorporating the mesh into the fascial closure. The aim of this retrospective study was to audit recurrence rate and surgical complications relating to this modified repair. METHODS: This study included all patients undergoing incisional hernia repair over a 5-year period under a single consultant. An initial stitch was taken through the Ultrapro(TM) mesh and fascia on one side of the defect followed by the fascia and mesh on the other side. By repeating this process with a continuous suture, the mesh was incorporated into the fascial defect closure. Telephone survey was performed, and where there was suspicion of a recurrence patients were brought back to the outpatient clinic. RESULTS: The study included 72 patients with a median follow-up of 29 months. There was a 7 % recurrence rate and a 10 % minor complication rate, with no patient requiring readmission or mesh removal. In 70 % of patients the procedure was performed as a day case and 90 % were satisfied with the repair. CONCLUSIONS: This is a promising new technique that aims to address suture line failure and the significant recurrence rate that occurs with incisional hernia repair.

Routine histological analysis of a macroscopically normal gallbladder--a review of the literature.

BACKGROUND: 70,000 cholecystectomies were performed in the United Kingdom in 2011-2012. Currently it is standard practice to submit all gallbladder specimens for routine histology to exclude malignancy. The aim of this systematic review was to establish whether a normal macroscopic appearance to the gallbladder at the time of cholecystectomy is sufficient to rule out malignancy and therefore negate the need for routine histology. METHODS: Relevant articles that were published between 1966 and January 2013 were identified through electronic databases. RESULTS: 21 studies reported on 34,499 histologically analysed specimens. 172/187 (92%) of gallbladder cancers demonstrated intra-operative macroscopic abnormality. Studies that opened the specimens intra-operatively identified all cancers, whereas gross macroscopic visualization resulted in 15 potentially missed cancers (p = 0.10). In patients of European ethnicity, gallbladder cancer in a macroscopically normal looking gallbladder was identified in only one study; however all of these patients were above the age of 60. The incidence of gallbladder cancer was significantly raised in ethnic groups from high risk areas (p = 0.0001). CONCLUSIONS: A macroscopically normal gallbladder in patients of European ethnicity under the age of 60 may not require formal histopathology. The best method for intra-operative examination may involve opening the specimen to allow inspection of the mucosa and wall, however this needs further investigation. In the context of the volume of gallbladder surgery being performed there is the potential for significant cost and time savings.

A national audit of antibiotic prophylaxis in elective laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic surgeons in Great Britain and Ireland were surveyed to assess their use of antibiotic prophylaxis in elective laparoscopic cholecystectomy. This followed a Cochrane review that found no evidence to support the use of antibiotic prophylaxis in routine cases. METHODS: Data were collected on routine use of antibiotics in elective laparoscopic cholecystectomy, and how that was influenced by factors such as bile spillage, patient co-morbidities and surgeons' experience. An online questionnaire was sent to 450 laparoscopic surgeons in December 2011. RESULTS: Data were received from 111 surgeons (87 consultants) representing over 7,000 cases per year. In routine cases without bile spillage, 64% of respondents gave no antibiotics and 36% gave a single dose. In cases with bile spillage, 11% gave no antibiotics. However, 80% gave one dose and 7% gave three doses. Co-amoxiclav was used by 75% of surgeons. Surgeons are more likely to give antibiotics when patients have risk factors for infective endocarditis. CONCLUSIONS: This study suggests over 20,000 doses of antibiotics and over £100,000 could be saved annually if surgeons modified their practice to follow current guidelines.

Secondary aorto-enteric fistula presenting over a 2-month period with recurrent gastrointestinal bleeding.

A female in her sixties presented with recurrent gastrointestinal bleeding over a two-month period requiring multiple hospital admissions. Inconclusive upper and lower gastrointestinal endoscopies in addition to an initial negative CT angiogram initially left the diagnosis uncertain. A subsequent catastrophic bleed prompted a further CT angiogram that demonstrated a fistula between the aorta and third part of the duodenum with active contrast extravasation. Emergency surgery was carried out but ultimately the patient did not survive.

Laparoscopic removal of a double gallbladder for cholelithiasis: a case report.

We describe the findings of symptomatic cholelithiasis in the double gallbladder of a 75-year-old woman, which was successfully removed laparoscopically. This report highlights the importance of this condition and the effectiveness of magnetic resonance cholangiopancreatography in defining abnormal gallbladder anatomy.

Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids.

The aim of this study was to test the hypothesis that gastric bacterial overgrowth is a side effect of acid suppression therapy in patients with gastroesophageal reflux disease (GERD) and that the bacteria-contaminated gastric milieu is responsible for an increased amount of deconjugated bile acids. Thirty patients with GERD who were treated with 40 mg of omeprazole for at least 3 months and 10 patients with GERD who were off medication for at least 2 weeks were studied. At the time of upper endoscopy, 10 ml of gastric fluid was aspirated and analyzed for bacterial growth and bile acids. Bacterial overgrowth was defined by the presence of more than 1000 bacteria/ml. Bile acids were quantified via high-performance liquid chromatography. Eleven of the 30 patients taking omeprazole had bacterial overgrowth compared to one of the 10 control patients. The median pH in the bacteria-positive patients was 5.3 compared to 2.6 in those who were free of bacteria and 3.5 in the control patients who were off medication. Bacterial overgrowth only occurred when the pH was >3.8. The ratio of conjugated to unconjugated bile acids changed from 4:1 in the patients without bacterial overgrowth to 1:3 in those with bacterial growth greater than 1000/ml. Proton pump inhibitor therapy in patients with GERD results in a high prevalence of gastric bacterial overgrowth. The presence of bacterial overgrowth markedly increases the concentration of unconjugated bile acids. These findings may have implications in the pathophysiology of gastroesophageal mucosal injury.

Toxic bile acids in gastro-oesophageal reflux disease: influence of gastric acidity.

BACKGROUND: Bile acid toxicity has been shown in the gastric, colonic, and hepatic tissues; the effect on oesophageal mucosa is less well known. AIMS: To determine the spectrum of bile acids refluxing in patients with gastro-oesophageal reflux disease and its relation to oesophageal pH using a new technique of combined oesophageal aspiration and pH monitoring. METHODS: Ten asymptomatic subjects and 30 patients with symptoms of gastro-oesophageal reflux disease (minimal mucosal injury, erosive oesophagitis (grade 2 or 3 Savary-Miller), Barrett's oesophagus/stricture; n=10 in each group) underwent 15 hour continuous oesophageal aspiration with simultaneous pH monitoring. Bile acid assay of the oesophageal samples was performed using modified high performance liquid chromatography. RESULTS: The peak bile acid concentration and DeMeester acid scores were significantly higher in the patients with oesophagitis (median bile acid concentration 124 micromol/l; acid score 20.2) and Barrett's oesophagus/stricture (181 micromol/l; 43. 3) than patients with minimal injury (14 micromol/l; 12.5) or controls (0 micromol/l; 11.1). The predominant bile acids detected were cholic, taurocholic, and glycocholic acids but there was a significantly greater proportion of secondary bile acids, deoxycholic and taurodeoxycholic acids, in patients with erosive oesophagitis and Barrett's oesophagus/stricture. Although bile acid reflux episodes occurred at variable pH, a temporal relation existed between reflux of taurine conjugates and oesophageal acid exposure (r=0.58, p=0.009). CONCLUSION: Toxic secondary bile acid fractions have been detected in patients with extensive mucosal damage. Mixed reflux is more harmful than acid reflux alone with possible toxic synergism existing between the taurine conjugates and acid.

Assessment of combined bile acid and pH profiles using an automated sampling device in gastro-oesophageal reflux disease.

BACKGROUND: Bile acid reflux is an important component of duodenogastro-oesophageal reflux but there is no effective method of quantifying it. The contribution of bile acids to oesophageal pH is unknown. METHODS: Oesophageal aspirates were collected over 15 h using a new automated suction device and pH was monitored in ten asymptomatic volunteers (group 1) and 30 patients with reflux oesophagitis (group 2, minimal mucosal injury; group 3, erosive oesophagitis; group 4, stricture or Barrett's oesophagus). Bile acid assay was performed by high-performance liquid chromatography. RESULTS: The concentration of bile acids was significantly higher in group 3 (median (interquartile range) 124 (50-301) mumol/l) and group 4 (181 (85-591) mumol/l) compared with group 1 (0 mumol/l) and group 2 (14 (0-100) mumol/l). Patients in groups 3 and 4 also had significantly greater DeMeester acid scores. Combined bile acid and oesophageal acid reflux was observed in eight of ten patients with stricture or Barrett's oesophagus. There was no correlation between total bile acid concentration and oesophageal acid or alkaline exposure. CONCLUSION: This study supports the theory of toxic synergism between acid and bile acids in reflux oesophagitis. Bile acids may contribute to the pathogenesis of Barrett's metaplasia.

Automated oesophageal reflux sampler--a new device used to monitor bile acid reflux in patients with gastro-oesophageal reflux disease.

A new automated suction device has been developed to aspirate the contents of the distal oesophagus to monitor the constituents of the refluxate in patients with gastro-oesophageal reflux disease. Using antimony and glass electrodes with solid-state pH recorders it has been conclusively shown that gastric acid is responsible for the mucosal damage seen in reflux oesophagitis but new evidence is emerging that other constituents of the gastroduodenal juice, in particular bile acids, are also damaging to the oesophageal mucosa. The main difficulty lies in that there is no reliable method of monitoring this component of the refluxate except by direct aspiration of the contents for assay. This new technique of oesophageal sampling utilizing a software-controlled suction process with simultaneous pH recording has helped to identify patients at risk of refluxing potentially harmful substances and is a valuable addition to the armamentarium of investigative procedures for patients with gastro-oesophageal reflux disease.

Pain relief after inguinal hernia repair: a randomized double-blind study.

A randomized double-blind study was undertaken using 0.5 per cent bupivacaine ilioinguinal field block and oral papaveretum-aspirin tablets to assess pain relief after hernia surgery. A consecutive series of 200 men undergoing repair of a unilateral inguinal hernia underwent random allocation into one of the four groups to receive: bupivacaine and papaveretum-aspirin (group 1), bupivacaine and oral placebo (group 2), saline and papaveretum-aspirin (group 3), or saline and oral placebo (group 4). Patients were prescribed postoperative opiates to be given on demand. Pain levels and mobility were assessed at 6 and 24 h after operation. Patients in group 1 reported significantly less pain, required less additional opiates and had better mobility than those in group 4 (pain score P < 0.001 at 6 h and P = 0.002 at 24 h) and group 3 (P = 0.002 for pain and mobility scores at 6 h). Bupivacaine alone provided good immediate postoperative pain relief (P = 0.002 group 2 versus group 4 at 6 h). The combination of bupivacaine and papaveretum-aspirin provided the best results and is suitable for day-case postoperative analgesia.

Evolving role of intensive and high-dependency care.

As stratified patient care evolves, and with an increasing population of elderly patients undergoing major surgery there is a growing demand for critical and high-dependency care beds. Results of an audit comparing the activity of a combined Intensive Care and High-Dependency Unit (ITU/HDU) in 1981 with 1991 has shown an increase in the number of patients admitted, particularly for high-dependency care. The overall mortality in 1981 was 12% compared with 9.5% in 1991. The greatest improvement was seen in ventilated patients, where the mortality was reduced from 54% in 1981 to 30% in 1991. An attempt is made to predict the demand for critical care and high-dependency beds for the future in a population of approximately 250,000 based on current trends. It is perceived that it will be necessary to establish a six-bed ITU and eight high-dependency surgical beds in two separate but adjacent units, where there will be a free interchange of skills at the different levels of care.

Spontaneous rupture of the oesophagus (Boerhaave's syndrome).

Five cases of spontaneous rupture of the oesophagus are reported. All cases had surgery within 12 hours, and all survived, illustrating the value of early diagnosis in this rare condition. None had their diagnosis made before admission to the hospital. Myocardial infarction is the commonest misdiagnosis and frequently results in delayed treatment. We believe that a simple direct question to enquire of the patient whether or not vomiting preceded the onset of the severe pain would significantly reduce the rate of misdiagnosis.