Ahmad Aly

Reflux after oesophagectomy

Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it.

Laparoscopic repair of large hiatal hernias

The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long‐term outcome of laparoscopic repair of large hiatal hernias.

Short term infusion of glycine-extended gastrin17 stimulates both proliferation and formation of aberrant crypt foci in rat colonic mucosa

Evidence is accumulating that gastrin precursors may act as growth factors for the colonic mucosa in vivo and for colorectal carcinoma cell lines in vitro. The effect of short term administration of synthetic gastrins on the colonic mucosa in vivo, however, has not been reported. The aim of our study was to determine whether continuous systemic infusion of glycine‐extended gastrin17 stimulated proliferation and accelerated carcinogenesis in the colorectal mucosa. A significant increase in colonic mucosal proliferation as assessed by metaphase index was seen in the caecum (23%, p < 0.02) and distal colon (27%, p < 0.001), but not the rectum, after treatment of intact rats with glycine‐extended gastrin17 for 1 week using implanted miniosmotic pumps. Defunctioning of the rectum reduced both the proliferative index and crypt height of the rectal mucosa of untreated rats. Treatment of rectally defunctioned animals with glycine‐extended gastrin17 for either 1 or 4 weeks resulted in a significant increase in both the proliferative index (40% and 93%, respectively) and crypt height (11% and 19%, respectively) of the rectal mucosa. The total number of aberrant crypt foci in intact rats treated with the procarcinogen azoxymethane plus glycine‐extended gastrin17 was increased by 48% compared to the value in controls treated with azoxymethane only (p = 0.01). We conclude that short term administration of glycine‐extended gastrin17 to mature rats not only has a proliferative effect upon colonic mucosa, but also increases the number of aberrant crypt foci formed in the colorectal mucosa after treatment with azoxymethane. Glycine‐extended gastrin17 could thus potentially act as a promoter of carcinogenesis.

Evolution of surgical treatment for pharyngeal pouch

The development of endoscopic techniques, particularly endoscopic stapling, has led to a re‐evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed.

Laparoscopic Repair of Very Large Hiatus Hernia With Sutures Versus Absorbable Mesh Versus Nonabsorbable Mesh A Randomized Controlled Trial

OBJECTIVE Determine whether absorbable or nonabsorbable mesh in repair of large hiatus hernias reduces the risk of recurrence, compared with suture repair. BACKGROUND Repair of large hiatus hernia is associated with radiological recurrence rates of up to 30%, and to improve outcomes mesh repair has been recommended. Previous trials have shown less short-term recurrence with mesh, but adverse outcomes limit mesh use. METHODS Multicentre prospective double blind randomized controlled trial of 3 methods of repair: sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome-hernia recurrence assessed by barium meal radiology and endoscopy at 6 months. Secondary outcomes-clinical symptom scores at 1, 3, 6, and 12 months. RESULTS A total of 126 patients enrolled: 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Among them, 96.0% were followed up to 12 months, with objective follow-up data in 92.9%. A recurrent hernia (any size) was identified in 23.1% after suture repair, 30.8% after absorbable mesh, and 12.8% after nonabsorbable mesh (P = 0.161). Clinical outcomes were similar, except less heartburn at 3 and 6 months and less bloating at 12 months with nonabsorbable mesh; more heartburn at 3 months, odynophagia at 1 month, nausea at 3 and 12 months, wheezing at 6 months; and inability to belch at 12 months after absorbable mesh. The magnitudes of the clinical differences were small. CONCLUSIONS No significant differences were seen for recurrent hiatus hernia, and the clinical differences were unlikely to be clinically significant. Overall outcomes after sutured repair were similar to mesh repair.

Antireflux anastomosis following oesophagectomy.

Background:  Reflux of duodeno‐gastric fluid is a significant problem after oesophagectomy with gastric conduit reconstruction. It can impact considerably upon the patients quality of life and can induce oesophagitis and Barretts metaplasia in the remnant oesophagus.

Embryonic parathyroid rests occur commonly and have implications in the management of secondary hyperparathyroidism.

Background:  Recurrence after surgery for secondary hyperparathyroidism is not infrequent. Regrowth of the residual parathyroid tissue after subtotal parathyroidectomy or of the autograft after total parathyroidectomy occurs in many cases. Supernumerary glands are also frequently cited as the offending cause and upon revisiting the neck, the surgeon may be surprised that such an obvious gland was ‘missed’ at the first operation. Indeed, multiple glands removed in sequential operations have been reported suggesting that they develop over time rather than being present from the start. It is possible that microscopic parathyroid ‘rests’ of embryological origin proliferate under the ongoing stimulus of renal failure to produce supernumerary glands after apparently adequate initial surgery for hyperparathyroidism. The aim of the present study was to determine whether such rests occur frequently or infrequently.

An Antireflux Anastomosis Following Esophagectomy: A Randomized Controlled Trial

BackgroundReflux of duodeno-gastric fluid is a significant problem after esophagectomy with gastric conduit reconstruction. Symptoms may be severe and impact considerably upon the quality of life. Previous studies have suggested that a fundoplication type anastomosis may limit post-esophagectomy reflux.AimThe purpose of this study was to determine whether a modified fundoplication at the gastro-esophageal anastomosis prevents reflux after esophagectomy.MethodsProspective multicenter randomized controlled trial to compare a conventional end of esophagus to side of gastric conduit anastomosis with a modified fundoplication anastomosis in patients undergoing esophagectomy with intrathoracic anastomosis. Major outcomes were reflux symptoms, symptoms of dysphagia, and complications.ResultsFifty-six patients were enrolled. The fundoplication anastomosis was associated with significantly lower incidence of reflux (40% vs 70%), as well as a reduced incidence of severe reflux (8% vs 30%). Disturbance of sleep due to reflux was significantly reduced in the fundoplication group (18% vs 47%) as was the incidence of respiratory symptoms. The fundoplication anastomosis was not associated with an increase in dysphagia, and there was no difference in complications between the two groups.ConclusionsFundoplication anastomosis during esophagectomy is effective in protecting patients from reflux symptoms after esophagectomy and improves quality of life, particularly with regard to sleep disturbance.

The use of over the scope clip (OTSC) device for sleeve gastrectomy leak.

Sleeve gastrectomy is increasing in popularity for the treatment of morbid obesity. The most significant complication posed is leak from the resection line. Typically, this occurs at the proximal end of the sleeve, adjacent the gastroesophageal junction. Such leaks can be notoriously persistent resulting in a chronic gastric fistula. Even when low in output, these fistulas rarely spontaneously resolve. It may mean months of poor health, multiple interventions and prolonged hospitalisation. Various strategies have been employed to aid closure of a sleeve leak, including “drain and wait”, stenting, biological glues, mesh plugs and mucosal clips, all with variable and unreliable success. Many cases ultimately come to complex revisional surgery employing resection or diversion as a solution, but sometimes yielding a less than ideal bariatric result. A simple endoscopic solution would be ideal to this difficult problem and potentially shift the paradigm of leak management. We report two consecutive cases of managing sleeve leak using an over-the-scope endoscopic clip (OTSC) device which differs from standard mucosal endoscopic clips by attempting full thickness or near full thickness circumferential closure of the area of perforation and discuss the technical aspects of this procedure.

Argon Plasma Coagulation and Gastric Bypass—A Novel Solution to Stomal Dilation

A patulous gastro-enterostomy after gastric bypass is a common cause of poor restriction and poor weight loss. Revisional surgery is an option but may be hazardous. This case report highlights the use of argon plasma coagulation by flexible endoscopy to reduce stomal size, improve restriction, and avoid revisional surgery.