Management of achalasia in the UK, do we need new guidelines?

Aim: It is recommended that management of complex benign upper gastrointestinal pathology is discussed at multi disciplinary team (MDT) meetings. American College of Gastroenterology (ACG) guidelines further recommend that treatment delivery is provided by high volume centres, with objective post-procedural investigations, in order to improve patient outcomes. We aimed to survey the current UK practice in the management of achalasia.

Buruli ulcer in a nine-month-old boy.

The diagnosis of Buruli ulcer should be considered in all painless undermined ulcers in the tropics. The diagnosis and treatment are a challenge in rural settings despite the well established tuberculosis programmes. Immediate commencement on rifampicin and streptomycin is essential to halt the progression of disease and to, hopefully, reverse it.

Laparoscopic stapled cardioplasty for failed treatment of achalasia.

Background: Treatment of primary achalasia includes injection of botulinum toxin, pneumatic dilatation or surgical myotomy. All of these procedures have an associated failure rate. Laparoscopic stapled cardioplasty (LSC) may be an alternative to failed pneumatic dilatation and laparoscopic Heller's myotomy where oesophagectomy has previously been the only surgical option.

Establishing pneumoperitoneum: Verres or Hasson? The debate continues.

Introduction: The technique of establishing pneumoperitoneum for laparoscopic surgery remains contentious, with various different techniques available and each having its own advocates. The Verres needle approach has attracted much criticism and is seen to entail more risk, but is this view justified in the era of evidence-based medicine?

Patients And Methods: Over a 6-year period, a prospective study was undertaken of 3126 patients who underwent laparoscopic surgery performed by two upper gastrointestinal surgeons. One surgeon preferred the Verres needle and the other an open technique.

Review of open and minimal access approaches to oesophagectomy for cancer.

Background: Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit.

Methods: Demographic and clinical data were entered into a prospective database.

Anatomical failure following laparoscopic antireflux surgery (LARS): does it really matter?

Introduction: Failure rates of laparoscopic antireflux surgery (LARS) vary from 2-30%. A degree of anatomical failure is common, and the most common failure is intrathoracic wrap herniation. We have assessed anatomical integrity of the crural repair and wrap using marking Liga clips placed at the time of surgery and compared this with symptomatic outcome.

Cost-effective laparoscopic cholecystectomy.

Introduction: There is wide variation in costs, both theatre and ward, for the same operation performed in different hospitals. The aim of this study was to compare the true costs for a large number of consecutive laparoscopic cholecystectomy (LC) cases using re-usable equipment with those from an adjacent trust in which the policy was to use disposable LC equipment.

Patients And Methods: Data were collected prospectively between January 2001 and December 2007 inclusive for all consecutive patients undergoing LC by two upper gastrointestinal (UGI) consultants at the Royal Berkshire Hospital.

Laparoscopic splenectomy and diaphragmatic rupture repair in a 27-week pregnant trauma patient.

Report of a 27-week pregnant woman having diaphragmatic rupture and intrathoracic ruptured spleen is presented. She was managed by laparoscopic reduction of the intrathoracic viscus, with repair of the defect and splenectomy.

Does laparoscopic antireflux surgery improve quality of life in patients whose gastro-oesophageal reflux disease is well controlled with medical therapy?

Objective: Both medical therapy and laparoscopic antireflux surgery have been shown to improve quality of life in gastro-oesophageal reflux disease. Although patients with poor symptom control or side effects on medical therapy might be expected to have improved quality of life after surgery, our aim was to determine, for the first time, whether patients whose symptoms are well controlled on medical therapy but who decide to undergo surgery (patient preference) would experience improved quality of life.

Methods: Retrospective analysis of our patient database (1998-2003, n=313) identified 60 patients who underwent laparoscopic antireflux surgery for the indication of patient preference.

Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry.

Background: Laparoscopic fundoplication is an accepted treatment for symptomatic gastro-oesophageal reflux disease. The aim of this study was to clarify whether total (Nissen) or partial (Toupet) fundoplication is preferable, and whether preoperative oesophageal manometry should be used to determine the degree of fundoplication performed.

Methods: Preoperative oesophageal manometry was used to stratify 127 patients with established gastro-oesophageal reflux disease into effective (75) and ineffective (52) oesophageal motility groups.

Laparoscopic anti-reflux surgery is effective in obese patients with gastro-oesophageal reflux disease.

Introduction: Obesity has long been regarded as a risk factor for the development of gastro-oesophageal reflux disease (GORD). It has been claimed that surgical efficacy of laparoscopic anti-reflux operations is decreased in obese patients. The aim of this study was to assess whether laparoscopic anti-reflux surgery is effective in obese patients with GORD compared to non-obese patients.

Laparoscopic subtotal cholecystectomy without cystic duct ligation.

Background: Cholecystectomy is made hazardous by distortion of the anatomy of Calot's triangle by acute or chronic inflammation. Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in difficult cases.

Methods: This prospective study included all cholecystectomies performed in a district general hospital upper gastrointestinal unit between 2003 and 2005, after the introduction of LSTC.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases.

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years.

Oesophageal pH monitoring using the Bravo catheter-free radio capsule.

Objectives: Oesophageal pH monitoring is the current standard for the diagnosis of gastro-oesophageal reflux disease. The Bravo capsule allows 48-h monitoring without the need for a naso-oesophageal catheter. Our aim was to assess the Bravo capsule in terms of patient discomfort and interference with daily activities, and to determine if 48-h Bravo pH studies facilitate the diagnosis of gastro-oesophageal reflux disease.

A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease.

Background: We aimed to determine if a poor response to proton pump inhibitors (PPIs) can predict a poor outcome following laparoscopic antireflux surgery (LARS) in our surgically treated population.

Methods: A total of 324 patients undergoing LARS were included in this study. Following standardized assessment, patients recorded the efficacy of their medication on visual analogue scales.

Results of thoracoscopic sympathectomy for the treatment of axillary and palmar hyperhidrosis with respect to compensatory hyperhidrosis and dry hands.

Background: We examined the results of thoracoscopic sympathectomy (TS) for palmar and axillary hyperhidrosis with respect to operative method, symptom control, patient satisfaction and complications.

Methods: We performed a retrospective review of patient records with mail and telephone questionnaire follow-up of 55 patients (15 men) with a median age of 26 years (range, 15-52) who underwent TS between February 1994 and December 2001.

Results: There were no differences in complication rates between those having bilateral TS (n = 23) and those having unilateral procedures (n = 20) with a median follow-up of 21 months (range, 2-94).

Routine day-case laparoscopic cholecystectomy.

Background: A prospective study was carried out to assess the feasibility of performing true day-case laparoscopic surgery in a district general hospital.

Methods: All patients admitted consecutively under the care of one surgeon for laparoscopic cholecystectomy were included in the study. Selection criteria for a day-case procedure included an American Society of Anesthesiologists grade of I or II and the availability of a responsible carer at home.

Multiport staging laparoscopy in esophageal and cardiac carcinoma.

Between February 1993 and September 2000, 320 patients with esophageal cancer were referred to our oesophagogastric unit. One hundred and thirty-three consecutive patients with histologically proven carcinoma of the esophagus were assessed with a view to resection using multiport staging laparoscopy. Multiport staging laparoscopy was performed as a short stay/day case procedure in 133 patients with esophageal and oesophagogastric junctional carcinoma.

Laparoscopic management of large paraesophageal hiatal hernia.

Background: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus.

Methods: Data were collected prospectively during an 8-year period.