Michael R. Cox

Laparoscopic cholecystectomy for acute inflammation of the gallbladder.

OBJECTIVE The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder. SUMMARY BACKGROUND DATA Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach. METHODS All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema. RESULTS The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation. CONCLUSIONS Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.

Prospective randomized comparison of open versus laparoscopic appendectomy in men.

Abstract. A prospective, randomized trial was performed to compare open appendectomy with laparoscopic appendectomy in men with a clinical diagnosis of acute appendicitis. Sixty-four patients with a median age of 25 years (range 18–84 years) were randomized to open appendectomy (n = 31) or laparoscopic (n = 33) appendectomy. Of the 64 men, 56 (87.5%) had appendicitis (27 open, 29 laparoscopic procedures). The mean operating times were 50.6 ± 3.7 minutes (± SEM) for open and 58.9 ± 4.0 minutes for laparoscopic appendectomy (p = 0.13). Five (15%) patients randomized to laparoscopic appendectomy had an open operation. The mean postoperative hospital stay was significantly longer for open appendectomy (3.8 ± 0.4 days) than for laparoscopic appendectomy (2.9 ± 0.3 days) (t = 2.05,df = 62,p = 0.045). The complication rate after open appendectomy (25.8%) was not significantly different from that after laparoscopic appendectomy (12.1%). There was a single postoperative death due to a pulmonary embolus in the laparoscopic group and a single death due to cardiac and renal failure in the open group. The mean time to return to normal activities was significantly longer following open appendectomy (19.7 ± 2.4 days) than after laparoscopic appendectomy (10.4 ± 0.9 days), (t = 3.75,df = 49,p = 0.001). In conclusion, laparoscopic appendectomy in men has significant advantages in terms of a more rapid recovery compared to open appendectomy. There were no significant disadvantages to laparoscopic appendectomy compared to open appendectomy.

Meta‐analysis: coeliac disease and the risk of all‐cause mortality, any malignancy and lymphoid malignancy

Coeliac disease has been associated with an increased risk of mortality and malignancy. However, the strength of this association is conflicting among different studies.

Evidence to Support the Use of Minimally Invasive Esophagectomy for Esophageal Cancer: A Meta-analysis

OBJECTIVE To use meta-analysis to compare oncologic outcomes of minimally invasive esophagectomy (MIE) with open techniques (thoracoscopic and/or laparoscopic). Analysis includes the extent of lymph node (LN) clearance, number of LNs retrieved, staging, geographic variance, and mortality. DATA SOURCES A systematic review of the literature was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using MEDLINE, PubMed, EMBASE, and the Cochrane databases (1950-2012). We evaluated all comparative studies. STUDY SELECTION All eligible published studies with adequate oncologic data comparing MIE with open resection for carcinoma of the esophagus or esophagogastric junction. DATA EXTRACTION Two investigators independently selected studies for inclusion and exclusion by article abstraction and quality assessment. DATA SYNTHESIS After careful review, we included 16 case-control studies with 1212 patients undergoing esophagectomy. The median (range) number of LNs found in the MIE and open groups were 16 (5.7-33.9) and 10 (3.0-32.8), respectively, with a significant difference favoring MIE (P = .04). In comparing LN retrieval in Eastern vs Western studies, we found a significant difference in Western centers favoring MIE (P < .001). No statistical significance in pathologic staging was found between the open and MIE groups. Generally, no statistically significant difference was found between the open and MIE groups for survival within each time interval (30 days and 1, 2, 3, and 5 years), although the difference favored the MIE group. In comparing survival outcomes in Eastern vs Western centers, a nonsignificant survival advantage (across all time intervals) was found for MIE in the Eastern (P = .28) and Western (P = .44) centers. CONCLUSIONS Minimally invasive esophagectomy is a viable alternative to open techniques. Meta-analytic evidence finds equivalent oncologic outcomes to conventional open esophagectomy.

Acute Surgical Unit: a new model of care.

The traditional on‐call system for the management of acute general surgical admissions is inefficient and outdated. A new model, Acute Surgical Unit (ASU), was developed at Nepean Hospital in 2006. The ASU is a consultant‐driven, independent unit that manages all acute general surgical admissions. The team has the same make up 7 days a week and functions the same every day, including weekends and public holidays. The consultant does a 24‐h period of on‐call, from 7 pm to 7 pm. They are on remote call from 7 pm to 7 am and are in the hospital from 7 am to 7 pm with their sole responsibility being to the ASU. The ASU has a day team with two registrars, two residents and a nurse practitioner.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials

BACKGROUND Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO). METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction. RESULTS THE RESULTS OF THE THREE RCTS DEMONSTRATED THAT SEMS RESULTED IN COMPARABLE MAJOR [ODDS RATIO (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs. CONCLUSIONS These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.

Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis

The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.

Folate intake and the risk of upper gastrointestinal cancers: A systematic review and meta‐analysis

There is conflicting evidence on the association between folate intake and the risk of upper gastrointestinal tract cancers. In order to further elucidate this relationship, we performed a systematic review and quantitative meta‐analysis of folate intake and the risk of esophageal, gastric, and pancreatic cancer.

Association between human papillomavirus (HPV) and oesophageal squamous cell carcinoma: a meta-analysis.

SUMMARY The oncogenic potential of human papillomaviruses (HPV) is well known in the context of cervical carcinoma; however, their role in the development of oesophageal squamous cell carcinoma (OSCC) is less clear. We aimed to determine the extent of the association between HPV infection and OSCC. A comprehensive literature search found 132 studies addressing HPV and OSCC in human cases, and a meta-analysis was performed using a random-effects model. There was evidence of an increased risk of OSCC in patients with HPV infection [odds ratio (OR) 2·69, 95% confidence interval (CI) 2·05-3·54]. The prevalence of HPV in OSCC was found to be 24·8%. There was an increased risk associated with HPV-16 infection (OR 2·35, 95% CI 1·73-3·19). Subgroup analyses showed geographical variance, with Asia (OR 2·94, 95% CI 2·16-4·00), and particularly China (OR 2·85, 95% CI 2·05-3·96) being high-risk areas. Our results confirm an increase in HPV infection in OSCC cases.

Hiatal hernia and the risk of Barrett's esophagus

Background and Aim:  Barretts esophagus has been associated with the presence of hiatal hernia; however, to date no meta‐analysis of the relationship has been performed. We aimed to conduct a systematic review and meta‐analysis, providing a quantitative estimate of the increased risk of Barretts esophagus associated with hiatal hernia.