Paul Leeder

A pre-operative elevated neutrophil: lymphocyte ratio does not predict survival from oesophageal cancer resection

BackgroundElevated pre-operative neutrophil: lymphocyte ratio (NLR) has been identified as a predictor of survival in patients with hepatocellular and colorectal cancer. The aim of this study was to examine the prognostic value of an elevated preoperative NLR following resection for oesophageal cancer.MethodsPatients who underwent resection for oesophageal carcinoma from June 1997 to September 2007 were identified from a local cancer database. Data on demographics, conventional prognostic markers, laboratory analyses including blood count results, and histopathology were collected and analysed.ResultsA total of 294 patients were identified with a median age at diagnosis of 65.2 (IQR 59-72) years. The median pre-operative time of blood sample collection was three days (IQR 1-8). The median neutrophil count was 64.2 × 10-9/litre, median lymphocyte count 23.9 × 10-9/litre, whilst the NLR was 2.69 (IQR 1.95-4.02). NLR did not prove to be a significant predictor of number of involved lymph nodes (Cox regression, p = 0.754), disease recurrence (p = 0.288) or death (Cox regression, p = 0.374). Furthermore, survival time was not significantly different between patients with high (≥ 3.5) or low (< 3.5) NLR (p = 0.49).ConclusionPreoperative NLR does not appear to offer useful predictive ability for outcome, disease-free and overall survival following oesophageal cancer resection.

Vascular invasion is not a risk factor in oesophageal cancer recurrence

AIM The outcome of the treatment of oesophageal cancer remains poor despite improved treatment modalities and recurrence remains a major problem despite improved staging and treatment. The aim was to identify the independent risk factors responsible in the recurrence of oesophageal cancer. METHODS The patients who had elective oesophagectomy (n = 244) with curative intent were studied. One hundred and eighty four patients had surgery alone, 44 patients had neo-adjuvant chemotherapy and surgery while 16 patients had neo-adjuvant chemotherapy, surgery and adjuvant chemotherapy. We have analyzed patients who had surgery alone (n = 184). Data was collected for demography, type of operation, histology, staging (TNM), vascular invasion (VI), differentiation of tumour, type of chemotherapy and recurrence of tumour. RESULTS The median age was 67 years (IQR 60, 71). The T1, T2, T3 distribution was 10%, 24% and 66% respectively. Forty percent had no nodal involvement (N0) and 60% had N1 stage disease. Twenty three percent of patients had vascular invasion. Univariate analysis of histo-pathological factors identified lymph node yield (p = 0.06), curative resection R0 (p = 0.004) and vascular invasion (VI) (P = 0.69) as prognostic indicators of recurrence. Multivariate analysis showed that number of lymph nodes yielded (p = 0.01) and R0 resection remain independent indicators of recurrence of tumour. However, VI (p = 0.2) and age at disease onset (p = 0.8) were not indicators of recurrence in oesophageal cancer patients. CONCLUSION R0 and lymph node yield may help to predict the recurrence of oesophageal cancer. However the presence of VI may not be a significant risk factor in disease recurrence.

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post‐GSP.

Is harmonic scalpel an effective tool for oesophagectomy

INTRODUCTION Use of electrocautery in oesophagectomy is standard; however, the introduction of the harmonic scalpel (HS) and its use has changed the methodology of oesophagectomy in recent years. We have assessed the efficiency of HS in oesophageal cancer surgery. The parameters studied were blood loss, transfusion rates, and postoperative complications. METHODS Our cohort included 142 patients who underwent elective oesophagectomy from January 1999 to December 2004. The control group was the patients undergoing electrocautery oesophagectomy (n=98) between 1999 and 2002. Furthermore, 44 patients who were operated with the HS were included in the study group. RESULTS The numbers of units transfused were significantly less in HS group (median 0) in comparison with controls (median 2), p=0.003. Median blood loss in HS and the controls was 500 and 700 ml respectively (p=0.123). Mortality in HS group was 2.27%compared to 3.06% in controls (p=0.14). The complication (principally respiratory) rate was only 13.6% of patients in HS group compared to 17.3% in the controls. CONCLUSION Our study shows that HS reduces transfusion rates and postoperative complications, highlighting it as a safe and effective alternative to traditional electrocautery.

Laparoscopic adjustable gastric band erosion and migration into the proximal jejunum

Laparoscopic adjustable gastric band (LAGB) insertion is a frequently performed surgical procedure for the treatment of morbid obesity throughout the world. It is regarded to be the least invasive of all gastric restrictive procedures with the benefits of fast insertion, adjustable restriction, reversibility, and anatomy preservation. It has proved to be an effective method of treatment for morbid obesity with a low rate of morbidity and mortality [1]. Here we present the case of a patient that had undergone LAGB insertion previously and presented acutely with nonspecific symptoms of abdominal pain and nausea. Our patient was found to have gastric erosion and LAGB migration into the proximal jejunum, causing small bowel obstruction and requiring laparoscopic removal of the gastric band. A review of the literature revealed previous reports of cases in which laparotomy and open removal had been undertaken [2], as well as disconnection of the connection tubing and allowing passage out through the gastrointestinal tract in the so-called let loose technique [3].

Clinical challenges and images in GI. Image 3: Inflammatory fibroid polyp.

uestion: A 60-year-old man presented with acute onset f central abdominal pain radiating into his back. He was achycardic with severe epigastric tenderness. Computed omography (CT) confirmed a perforated viscus, most robably upper gastrointestinal in origin (Figure A). At laparotomy, a Billroth II gastrectomy was performed or a perforation found in the bed of thickened gastric ucosa within the antrum of the stomach (Figure B). The atient made an excellent recovery and was discharged 8 ays postoperatively. Interestingly, histopathologic examiation of the resected stomach revealed no malignancy, but isplayed fibrous stoma with prominent blood vessels and rincipally an eosinophilic inflammatory infiltrate (Figure ). Variable numbers of mononuclear cells, plasma cells, ast cells, and neutrophils were also seen. This differs from the histology of a perforated chronic pepic ulcer. An ulcer would demonstrate the presence of granlation tissue full of lymphocytes and plasma cells rather han the appearance of eosinophil-rich infiltrate shown in he slide. Mixed in with the granulation tissue seen in a eptic ulcer, one finds dense bands of collagen whereas in his case stroma is seen, which adds to the unique appearnce of the pathologic process that has taken place. What is the most likely diagnosis? Look on page 1808 for the answer and see the ASTROENTEROLOGY web site (www.gastrojournal.org) or more information on submitting your favorite mage to Clinical Challenges and Images in GI. IMRAN BHATTI, MBChB, MRCS RACHEL MELHADO, MBBS, MD, MRCS PAUL LEEDER, MBBS, MD, FRCS Department of Surgery DAVID SEMERARO, MBChB, FRCPath Department of Pathology GILLIAN TIERNEY, MBBS, MD, FRCS Department of Surgery Derby City General Hospital Derby, United Kingdom

Upper gastrointestinal surgeon attitudes towards management of refractory gastroesophageal reflux disease in obese patients

Aim: The marked increase in prevalence of obesity has been associated with an increase in obese patients seeking surgical treatment for refractory gastroesophageal reflux disease (GORD). The management of GORD in such patients remains contentious with no published guidelines. Methods: A snapshot 9-item online survey was undertaken to elicit professional opinions of UK surgeons regarding the surgical management of refractory GORD in obese patients. Results: Eighty-two percent and 51% of surgeons performed more than 10 anti-reflux procedures and more than 10 bariatric procedures per year, respectively. Nearly 80 of responders would consider laparoscopic fundoplication as the preferred option for management of refractory GORD in patients with body mass index (BMI) of 30-34.9 kg/m. In contrast, 58% and 80% would discuss bariatric surgery as an alternative treatment option for refractory GORD in patients with BMI 35-39.9 and ≥ 40 kg/m, respectively. Moreover, a bariatric procedure was considered the preferred option by 74% of respondents for patients with BMI ≥ 40 kg/m with refractory GORD, and by 58% for BMI ≥ 35 patients with refractory GORD and significant comorbidities. Eighty percent of surgeons agreed that laparoscopic Roux en-Y gastric bypass (LRYGB) was the preferred bariatric procedure for the management of obese patients with documented GORD. Conclusion: Our survey demonstrated that amongst UK upper gastrointestinal surgeons, bariatric surgery, specifically LRYGB, was a preferred option for management of patients with a BMI ≥ 35 kg/m and refractory GORD. Updated national guidelines are necessary to inform consensus on the management of GORD in obese patients.

LAGB: Complications–Diagnosis and Management

Gastric Band Complications are relatively common but rarely serious in nature. Complications can be classified as general or specific to band surgery. General complications are rare and gastric band surgery remains one of the safest forms of weight loss surgery available.

Predictors of inadequate excess weight loss 12-months after laparoscopic Roux en-Y gastric bypass for morbid obesity.

conducted at seven U.S. sites implants (Dec. 2007 t0 May 2008), and study II included 576 participants at 16 US sites (Aug, 2009 to March, 2011). All were private practices with only 1 practice participating in both studies. At the time of closing out data collection, trial I was complete and 5-year data on all participants available; and for trial II, all had completed 3 years, so only data to 3 years was included. Explants were defined as removing the LB without simultaneous replacement. Results: Yearly explant numbers and rates are presented for both studies for 3 years and study I for years 4 and 5. (See Table) ** Of the 9 in year 5, 7 were from one practice where patients were offered free removal of the LB at the end of the study. All 7 were performed in relation to the study end and several of these in the months following study closure but were planned within the study period. Conclusions: Explant rates in both studies are similar and much lower than the 32.5% safety signal at 5 years. This report reflects the literature from practices using LAGB surgery and mirror the change with time reported in these practices. There have been changes in band design, placement technique and adjustment practices, all of which may have contributed to the major fall in LB explants. UPLOAD-203147-_Laparoscopic adjustable gastric band explanation rates have varied greatly in the literature.pdf