Tom Wiggins

Laparoscopic adhesiolysis for acute small bowel obstruction: systematic review and pooled analysis

AbstractBackgroundAdhesional small bowel obstruction (SBO) occurs in 14–17xa0% of patients within 2xa0years of open colorectal or general surgery. The aim of this pooled analysis is to compare the safety and efficacy of laparoscopic versus open treatment of SBO.nMethodsAn electronic search of Embase, Medline, Web of Science, and Cochrane databases was performed. Weighted mean differences (WMDs) were calculated for the effect size of laparoscopic surgery on continuous variables, and pooled odds ratios (PORs) were calculated for discrete variables.nResultsThere were eleven non-randomized comparative studies included this review. Laparoscopic surgery was associated with a significant reduction in mortality (PORxa0=xa00.31; 95xa0% CI 0.16–0.61; Pxa0=xa00.0008), overall morbidity (PORxa0=xa00.34; 95xa0% CI 0.27–0.78; Pxa0<xa00.0001), pneumonia (PORxa0=xa00.31; 95xa0% CI 0.20–0.49; Pxa0<xa00.0001), wound infection (PORxa0=xa00.29; 95xa0% CI 0.12–0.70; Pxa0=xa00.005), and length of hospital stay (WMDxa0=xa0−7.11; 95xa0% CI −8.47 to −5.75; Pxa0<xa00.0001). The rates of bowel injury and reoperation were not significantly different between the two groups. Operative time was significantly longer in the laparoscopic group (WMDxa0=xa072.31; 95xa0% CI 60.96–83.67; Pxa0<xa00.0001).ConclusionLaparoscopic surgery for treatment of adhesional SBO improves clinical outcomes and can be performed safely in selected cases with similar rates of bowel injury and reoperation to open surgery. Large scale randomized controlled trials are needed to validate the findings of this pooled analysis of non-randomized data.

Quantification of phenol in urine headspace using SIFT-MS and investigation of variability with respect to urinary concentration

To quantify phenol in human urine or exhaled breath using selected ion flow tube mass spectrometry (SIFT-MS) requires a careful study of its reactions with the appropriate SIFT-MS precursor ions in the presence of water vapour. The reactions of NO+ precursor ions with the isobaric compounds phenol and dimethyl disulphide (DMDS) have been studied using the SIFT technique to identify the appropriate product ions in order to optimise the SIFT-MS kinetics library entries for these compounds. This allows accurate quantification when these compounds co-exist in humid biofluids, in particular urine headspace and exhaled breath. These optimised kinetics library entries have been used to investigate the effect of hydration status of healthy individuals on the concentration of phenol in their urine. Using these new kinetics, it is seen that hydration status of the donor volunteers (assessed using urinary osmolality and creatinine concentration) affects urinary headspace phenol concentrations measured via SIFT-MS. A strong correlation between headspace phenol concentration and both the urinary osmolality and urinary creatinine concentration has been demonstrated. Thus, to obtain urinary concentrations of phenol by headspace analyses using SIFT-MS it is essential to account for the osmolality or creatinine concentration of the urine.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions

In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high‐volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions.

Diagnostic Metabolomic Blood Tests for Endoluminal Gastrointestinal Cancer—A Systematic Review and Assessment of Quality

Advances in analytics have resulted in metabolomic blood tests being developed for the detection of cancer. This systematic review aims to assess the diagnostic accuracy of blood-based metabolomic biomarkers for endoluminal gastrointestinal (GI) cancer. Using endoscopic diagnosis as a reference standard, methodologic and reporting quality was assessed using validated tools, in addition to pathway-based informatics to biologically contextualize discriminant features. Twenty-nine studies (15 colorectal, 9 esophageal, 3 gastric, and 2 mixed) with data from 10,835 participants were included. All reported significant differences in hematologic metabolites. In pooled analysis, 246 metabolites were found to be significantly different after multiplicity correction. Incremental metabolic flux with disease progression was frequently reported. Two promising candidates have been validated in independent populations (both colorectal biomarkers), and one has been approved for clinical use. Networks analysis suggested modulation of elements of up to half of Edinburgh Human Metabolic Network subdivisions, and that the poor clinical applicability of commonly modulated metabolites could be due to extensive molecular interconnectivity. Methodologic and reporting quality was assessed as moderate-to-poor. Serum metabolomics holds promise for GI cancer diagnostics; however, future efforts must adhere to consensus standardization initiatives, utilize high-resolution discovery analytics, and compare candidate biomarkers with peer nonendoscopic alternatives. Cancer Epidemiol Biomarkers Prev; 25(1); 6–15. ©2015 AACR.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK

BackgroundEvidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood.MethodsIn this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998–2012) and USA (National Inpatient Sample 1998–2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England.ResultsPatients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; pu2009<u20090.001). Pre-treatment (1 vs. 2xa0days; pu2009<u20090.001) and total ( 4 vs. 7xa0days; pu2009<u20090.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; pu2009<u20090.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission.ConclusionThis study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.

Laparoscopic surgery for perforated peptic ulcer: an English national population-based cohort study

BackgroundRandomized controlled trials have shown that laparoscopic approach to surgery for perforated peptic ulcer (PPU) is associated with improved short-term outcomes; however, there is limited evidence concerning national practice. The aim of this investigation was to evaluate the effect of laparoscopic approach to PPU surgery upon mortality and morbidity in England.MethodsPatients with a primary diagnosis of PPU, admitted as an emergency to a hospital in England, and receiving surgical intervention, between 2005 and 2012 were identified from the Hospital Episode Statistics database. Outcomes analyzed included 30-day and 90-day mortality, 30-day complications, and length of hospital stay. Univariate and multivariate analyses were used to identify patient, hospital, and treatment-related factors associated with use of laparoscopy and mortality.ResultsThe study included 13,022 patients who underwent emergency surgery for PPU in England over an 8-year period. From 2005 to 2012, the utilization of laparoscopic surgery for PPU increased from 0 to 13% and was more commonly used in high volume emergency centers. Laparoscopic surgery was associated with significant reductions in 30-day (7% vs. 15.7%; Pu2009<u20090.001) and 90-day mortality (8.9% vs. 19.6%; Pu2009<u20090.001), pneumonia (6% vs. 10.1%; Pu2009<u20090.001), ischemic cardiac events (1% vs. 2.4%; Pu2009=u20090.007), as well as length of hospital stay (median 5 vs. 7 days; Pu2009<u20090.001). Factors associated with a reduced utilization of laparoscopic surgery included ageu2009≥u200970xa0years (Odds ratio (OR)u2009=u20090.58 (95% CI) 0.49–0.68) and Charlson Comorbidity Index scoreu2009≥u20092 (ORu2009=u20090.73; 95% CI 0.57–0.94).ConclusionThe rate of laparoscopic repair of PPU is increasing at a national level and more common in high volume emergency centers. It is associated with reduced rates of mortality; pneumonia and shorter length of hospital stay, highlighting the need for strategies to improve dissemination of laparoscopic techniques necessary for PPU repair.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study

BackgroundAcute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.MethodsData from all consecutive elderly patients (≥u200980xa0years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.Results47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (nu2009=u200942,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (pu2009<u20090.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (pu2009<u20090.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10–0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.ConclusionAcute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

Assessment of a Noninvasive Exhaled Breath Test for the Diagnosis of Oesophagogastric Cancer

Importance Early esophagogastric cancer (OGC) stage presents with nonspecific symptoms. Objective The aim of this study was to determine the accuracy of a breath test for the diagnosis of OGC in a multicenter validation study. Design, Setting, and Participants Patient recruitment for this diagnostic validation study was conducted at 3 London hospital sites, with breath samples returned to a central laboratory for selected ion flow tube mass spectrometry (SIFT-MS) analysis. Based on a 1:1 cancer:control ratio, and maintaining a sensitivity and specificity of 80%, the sample size required was 325 patients. All patients with cancer were on a curative treatment pathway, and patients were recruited consecutively. Among the 335 patients included; 172 were in the control group and 163 had OGC. Interventions Breath samples were collected using secure 500-mL steel breath bags and analyzed by SIFT-MS. Quality assurance measures included sampling room air, training all researchers in breath sampling, regular instrument calibration, and unambiguous volatile organic compounds (VOCs) identification by gas chromatography mass spectrometry. Main Outcomes and Measures The risk of cancer was identified based on a previously generated 5-VOCs model and compared with histopathology-proven diagnosis. Results Patients in the OGC group were older (median [IQR] age 68 [60-75] vs 55 [41-69] years) and had a greater proportion of men (134 [82.2%]) vs women (81 [47.4%]) compared with the control group. Of the 163 patients with OGC, 123 (69%) had tumor stage T3/4, and 106 (65%) had nodal metastasis on clinical staging. The predictive probabilities generated by this 5-VOCs diagnostic model were used to generate a receiver operator characteristic curve, with good diagnostic accuracy, area under the curve of 0.85. This translated to a sensitivity of 80% and specificity of 81% for the diagnosis of OGC. Conclusions and Relevance This study shows the potential of breath analysis in noninvasive diagnosis of OGC in the clinical setting. The next step is to establish the diagnostic accuracy of the test among the intended population in primary care where the test will be applied.

The influence of hospital volume upon clinical management and outcomes of esophageal achalasia: an English national population-based cohort study

Management of achalasia is potentially complex. Previous studies have identified equivalence between pneumatic dilatation and surgical cardiomyotomy in terms of clinical outcomes. However, previous research has not investigated whether a management strategies and outcomes are different in high-volume achalasia centers. This national population-based cohort study aimed to identify the treatment modalities utilized in centers, which regularly manage achalasia and those which manage it infrequently. This study also assessed rates of re-intervention and complications to establish if a volume-outcome relationship exists for the management of achalasia in England. In this study, the Hospitals Episode Statistics database was used to identify all patients treated for achalasia in England from 2002 to 2012. Primary treatment was defined as surgical cardiomyotomy, sequential pneumatic dilatation, or botulinum toxin therapy. Primary outcome measure was reintervention. Centers were divided into regular achalasia centers (≥5.7 cases per annum) and infrequent achalasia centers (<5.7 cases per annum), and were analyzed according to tertiary cancer center status. In total, there were 7,487 patients treated for achalasia. Out of 1,947 cases (26%) were treated in regular achalasia centers, with 5,540 (74%) treated in infrequent centers. In binary logistic regression modeling regular centers treated a similar proportion of patients with primary surgical cardiomyotomy (OR: 1.11 (95% CI 0.98-1.27)) and had similar rates of re-intervention to infrequent achalasia centers (HR: 1.03 (0.94-1.12)). RA-CUSUM analysis demonstrated no relationship between total hospital volume and reintervention rates. Tertiary cancer centers treated more achalasia patients with primary surgical cardiomyotomy (OR: 1.51 (95% CI 1.31-1.73)) but there was no significant difference in reintervention rates (OR: 1.05 (95% CI 0.95-1.16)). In conclusion, this analysis failed to demonstrate a volume-outcome relationship in the management of achalasia in England. This study highlights that achalasia is treated infrequently by the majority of centers.

OC-075 Management and outcomes of oesophageal perforation: a national study of 2564 patients in england

Introduction Traditionally oesophageal perforation is a rare clinical emergency that confers a high rate of mortality and major morbidity. The aim of the present study was to determine patient and hospital-related factors associated with mortality from oesophageal perforation. Method Patients admitted with a diagnosis of oesophageal perforation between 2001–2012 were identified. Comparative analysis was performed for the effect of hospital volume on clinical outcomes. Quartile thresholds used to divide hospitals were 1–14 (Lowest Volume (LV)), 15–20 (Low Middle Volume (LMV)), 21–35 (High Middle Volume (HMV)), and ≥36 cases (High Volume (HV)). Results Over the twelve-year study period 2,564 patients with oesophageal perforation were treated at 158 hospitals. The 30-day and 90-day mortality rates were 30.0% and 38.8% respectively. There was a significant increase in the percentage of patients managed supportively and a reduction in surgical management over time. Furthermore there were significant reductions in 30-day (36.6% to 24.9%; P < 0.001) and 90-day mortality (44.1% to 35.4%; P = 0.006) over the 12-year study period. Important patient demographics associated with 30-day and 90-day mortality included age ≥70, preoperative congestive cardiac failure, ischaemic heart, liver, and renal disease. High hospital volume was associated with significant reductions in 30-day (OR = 0.68; P = 0.001) and 90-day mortality (OR = 0.69; P = 0.001). Subset analysis of patients undergoing endoscopic intervention, identified hospital volume as an important factor associated with mortality. Conclusion This study provides evidence for the centralization of management of oesophageal perforation to high volume centres with appropriate multi-disciplinary infrastructure to treat these complex patients. Disclosure of interest None Declared.