Online education for safer opioid prescribing in hospitals-lessons learnt from the Opioid Use Change (OUCh) project.

Background: Opioids are often required for acute inpatient pain relief but lack of knowledge about common and less common long-term side effects can lead to inappropriate discharge prescribing. There are few validated educational tools available for junior prescribers on hospital wards. Education around opioid prescribing and deprescribing remains limited in the undergraduate curriculum and yet almost all controlled drug prescribing in hospitals is done by junior doctors.

Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy.

Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. The pathogenesis of CAP in the context of cholecystitis is unknown but is possibly related to the inflammatory process in the vicinity of the cystic artery, leading to weakness in the wall of the artery. Though CAP has been reported in the literature, our patient had a unique presentation in the presence of a cholecystostomy catheter in situ.

Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma.

The poor outcomes in esophageal adenocarcinoma (EAC) prompted us to interrogate the pattern and timing of metastatic spread. Whole-genome sequencing and phylogenetic analysis of 388 samples across 18 individuals with EAC showed, in 90% of patients, that multiple subclones from the primary tumor spread very rapidly from the primary site to form multiple metastases, including lymph nodes and distant tissues-a mode of dissemination that we term 'clonal diaspora'. Metastatic subclones at autopsy were present in tissue and blood samples from earlier time points.

Mediastinal herniation of the biliary tract leading to bile duct: obstruction following oesophagectomy.

Surgical management of oesophageal and gastro-oesophageal junction malignancies is one of the most challenging situations confronting the surgeon. Attaining a complete circumferential resection margin of lower-third oesophageal and gastro-oesophageal junction locally advanced carcinomas requires en-bloc resection of the hiatus and all the peri-oesophageal tissue and pleura. This results in an increased risk of herniation of the abdominal organs through the enlarged hiatus, which carries significant risk of morbidity and mortality.

Endoluminal Vacuum Therapy (E-Vac): A Treatment Option in Oesophagogastric Surgery.

Background: Leaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery.

Methods: A piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture.

Spontaneous diaphragmatic rupture following robotic prostatectomy.

Robotic surgery is an established therapy for localised prostate cancer and is replacing conventional laparoscopic prostatectomy in developed countries. Port-site hernia is a recognised, albeit small, risk following laparoscopic or robotic surgery. We report a case of spontaneous rupture of the right hemidiaphragm following robotic prostatectomy.

Iatrogenic oesophageal perforation during placement of an endoscopic vacuum therapy device.

Endoscopic vacuum-assisted closure (VAC) is increasingly being used as a means of managing perforations or anastomotic leaks of the upper gastrointestinal (GI) tract. Published outcomes are favourable, with few mentions of complications or morbidity. We present a case in which the management of a gastric perforation with endoscopic vacuum therapy was complicated by cervical oesophageal perforation.

Trimodality therapy and definitive chemoradiotherapy for esophageal cancer: a single-center experience and review of the literature.

In the UK, the standard of care for esophageal cancer has generally combined surgery with neoadjuvant chemotherapy, with definitive chemoradiotherapy (dCRT) being reserved for certain subgroups. Chemoradiotherapy followed by surgery (trimodality therapy) has not been widely adopted. The outcomes of patients undergoing dCRT or trimodality therapy at our cancer center between 2004 and 2012 were restrospectively analyzed.

ERCP and endoscopic sphincterotomy (ES): a safe and definitive management of gallstone pancreatitis with the gallbladder left in situ.

Background And Aims: UK guidelines recommend that patients with gallstone pancreatitis have cholecystectomy within 2 weeks of their pancreatitis. A proportion of these are elderly with significant comorbidities rendering them high risk for general anaesthesia and surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) may offer a safe alternative to cholecystectomy as definitive treatment in these patients.

Can the rat be used as a valid model of human esophageal adenocarcinoma?

Animal models of Barrett's metaplasia and esophageal adenocarcinoma are important to further characterize the disease and test potential therapies. This paper reviews the development of the surgical model of esophageal adenocarcinoma in the rat and considers whether this model provides a biologically accurate representation of Barrett's esophagus and esophageal adenocarcinoma in humans.

Assessment of cosmetic outcome after laparoscopic cholecystectomy among women 4 years after laparoscopic cholecystectomy: is there a problem?

Background: Advocates of single-port laparoscopic cholecystectomy (SPLC) claim that improved cosmetic outcome is one of its main benefits over conventional laparoscopic cholecystectomy (CLC). However, the published data quantifying the cosmetic outcome after CLC is sparse. This study aimed to determine the cosmetic outcome after CLC using a validated scar assessment tool.

Security swipe cards and scanners are a potential reservoir for hospital-acquired infection.

Introduction: Hospital-acquired infections complicate 10% of hospital admissions resulting in increased morbidity, mortality and cost to hospitals. Most hospitals issue doctors with plastic swipe cards that function as electronic keys to access clinical areas. The card is handled many times a day, often before direct patient contact.

Randomized trial of laparoscopic v open nephrectomy.

Background And Purpose: Clayman and associates first described laparoscopic nephrectomy in 1990. This paper describes the first randomized controlled trial to compare laparoscopic with open surgery for simple and radical nephrectomy.

Patients And Methods: Between 2001 and 2004, 45 patients requiring simple or radical nephrectomy (tumors as large as 8 cm) were randomized to either open surgery through a loin incision or laparoscopic nephrectomy (transperitoneal).

Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction.

Background: We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction.

Methods: A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period.

Results: Thirteen patients underwent successful LGJ and 10 had successful DS.

Endoscopy waiting times and impact of the two week wait scheme on diagnosis and outcome of upper gastrointestinal cancer.

The NHS has introduced the two week wait scheme to detect upper gastrointestinal cancers at an early stage and improve survival rates The aim of this study was to assess the impact of this scheme and changes in endoscopy waiting times on tumour stage and resection rates over a four year period. Data were analysed prospectively for all patients diagnosed with oesophagogastric cancer between September 1998 and September 2002 and from those referred under the two week wait scheme since its introduction in 2000. Of those tumours diagnosed by this scheme (15%) only 5% were early disease (stage 1 or 2).

Changes in functional gastrointestinal symptoms as a result of antireflux surgery.

Background: This study identifies how functional symptoms are altered after antireflux surgery and whether there are any predictors of such change.

Methods: A total of 206 patients underwent successful laparoscopic Nissen fundoplication. A questionnaire was sent at a median of 4.

Laparoscopic resection of gastric gastrointestinal stromal tumors.

Background: Gastrointestinal stromal tumors (GISTs) are neoplasms with low malignant potential. They occur most commonly in the stomach, where they are amenable to laparoscopic resection.

Methods: A case note review of all patients undergoing laparoscopic resection of a presumed gastric GIST at the Norfolk and Norwich University Hospital, United Kingdom, was conducted.

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux.

Background: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial.

Methods: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry.

Stapled laparoscopic cystgastrostomy: a series with 15 cases.

Background: The goal of this study was to assess the clinical outcome of patients undergoing laparoscopic stapled cystgastrostomy for pancreatic pseudocysts in contact with the posterior wall of the stomach.

Methods: We performed a case note review of all patients who have undergone stapled laparoscopic cystgastrostomy in Norwich, UK. The cystgastrostomy was fashioned through an anterior gastrotomy using a vascular ETS stapling device in all cases.

Attendance at a pain clinic with severe chronic pain after open and laparoscopic inguinal hernia repairs.

Background: The aim was to compare the frequency of severe chronic pain that required attendance at a pain clinic after open and laparoscopic inguinal hernia repairs.

Methods: This was a retrospective analysis of 7999 patients who underwent inguinal hernia repair between January 1994 and December 2001. The definition of severe chronic pain was pain related to inguinal hernia surgery that was bad enough for the patient to seek further medical help and be referred to the specialist pain clinic after exclusion of surgically correctable pathology such as hernia recurrence.

Vitamin E deficiency and metabolic deficits in neuronal ceroid lipofuscinosis described by bioinformatics.

The mnd mouse, a model of neuronal ceroid lipofusinosis (NCL), has a profound vitamin E deficiency in sera and brain, associated with cerebral deterioration characteristic of NCL. In this study, the vitamin E deficiency is corrected using dietary supplementation. However, the histopathological features associated with NCL remained.