Aim: The objective of this study was to evaluate high-resolution impedance manometry (HRIM) findings in patients with esophageal epiphrenic diverticulum. Methods: Patients with esophageal epiphrenic diverticulum who underwent HRIM between October 2008 and March 2012 are included in the study. Manometric findings were compared to endoscopic (EGD) and barium swallow (BS) findings. Patients with previous foregut surgery were excluded. Results: Six patients (mean age 59.0 years, 3 females) are included in the study. On EGD the diverticulum was 1 to 4 cm above the gastro-esophageal junction (GEJ) and the mouth of diverticulum was 2 to 9 cm in size. Mean lower esophageal sphincter pressure (LESP) and mean Integrated relaxation pressure (IRP) were 50.7 mmHg (range 39.2 to 61.9 mmHg) and 22.4 mmHg (range 13.8 to 30.8 mmHg) respectively. Achalasia was the most common abnormality noted in 3 patients (type I=2 and type II=1). Two additional patients had isolated EGJ obstruction with preserved esophageal motility. One patient had normal IRP but weak peristalsis. A break in peristalsis corresponding to themouth of the diverticulum could be seen in 4 patients. There was decreased bolus transit in three patients. Conclusions: There is a high prevalence of esophageal outflow obstruction and primary peristaltic abnormality in patients with epiphrenic diverticulum. This reconfirms the need to extend the myotomy down on to the GEJ even in patients in whom the diverticulum appears to be well above the GEJ.

Background. Achalasia may lead to cachexia if not diagnosed in an early stage. Surgery in cachectic patients is hazardous and complications may result in a protracted recovery or even death. Different treatment options have been described. In this paper, we report a stepwise surgical laparoscopic approach which appears to be safe and effective. Methods. Over a one-year period, a patient with a body mass index (BMI) below 17 being treated for anorexia nervosa was referred with dysphagia. Because of the extreme cachexia, a laparoscopic feeding jejunostomy (LFJ) was fashioned to enable long-term home enteral feeding. The patient underwent a laparoscopic Heller myotomy (LHM) when the BMI was normal. Results. The patient recovered well following this stepwise approach. Conclusion. Patients with advanced achalasia usually present with extreme weight loss. In this small group of patients, a period of home enteral nutrition (HEN) via a laparoscopically placed feeding jejunostomy allows weight gain prior to safe definitive surgery.

Background Self-expanding metal stents (SEMS) are an accepted intervention for malignant dysphagia. Stents vary in ease of insertion, removability, migration and occlusion rates. This series reports the complications, morbidity and mortality associated with several SEMS.Method: A prospective database of patients undergoing fluoroscopic guided oesophageal stent insertion for malignancy between June 2001 and June 2009 was analysed. Patient demographics, intervention outcomes and tumour variables were correlated with stent failure and patient survival. Multivariate analysis was performed to evaluate predictors for stent failure.Results: Two hundred and seventy-three stents were deployed using nine different types of SEMS. The median Mellow-Pinkas dysphagia score significantly improved from 3 to 1 post-stent insertion (P < 0.001), with a technical success rate of 98%. Stent complications occurred in 95 (36%) patients [recurrent dysphagia n = 49 (19%), migration n = 24 and occlusion n = 25]. Multivariate analysis demonstrates that the covered Niti S stent fails significantly more than the double-layered Niti S stent (OR = 4, P < 0.005).Conclusion: Oesophageal stent insertion provides good palliation for malignant dysphagia, however recurrent dysphagia remains a problem. This major complication occurs more frequently with covered Niti S stents than double-layered Niti S stents. This finding may aid the stent choice used in advanced oesophageal malignancy. J. Surg. Oncol. 2012;105:60-65. (C) 2011 Wiley Periodicals, Inc.

Objective: We aimed to analyze trends in litigation following laparoscopic cholecystectomy (LC) in England and compare our findings with data from the United States.Background: Several studies from the United States have highlighted the medico- legal repercussions of complications following LC. In 2007-2008, litigation claims cost the National Health Service in England over 660 million Great British Pounds (GBP) (1.1 billion USD). Despite this, there has been little examination of litigation following LC in England.Methods: Data from the National Health Service Litigation Authority on clinical negligence claims between 1995 and 2009 following LC were obtained and analyzed.Results: Four hundred eighteen claims were made of which 303 were settled. One hundred ninety-eight (65%) were found to be in the claimants favor for a total cost of 20.4 million GBP (33.4 million USD). Litigation claims have leveled since 2001. Operator error was the most likely cause to result in a claim and the only cause associated with a successful claim (P = 0.023). A delay in the recognition of complications was the second most common reason for initiation of a claim. Bile duct injury was the most frequent injury resulting in litigation and the most likely injury associated with a successful claim (P < 0.001). The average payout for a successful claim was 102,827 GBP/168,337 USD. Findings from US studies were similar, although the magnitude of payouts was 4 times higher.Conclusion: Strategies that minimize bile duct injury and speed up recognition of injuries should be adopted to reduce the litigation burden and improve patient care.

PURPOSE:Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.METHODS:Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.RESULTS:In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.CONCLUSION:Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.

The resection of oesophageal cancer offers the only chance of cure. The introduction of minimally invasive oesophagectomy has gained wide acceptance for the surgical treatment of oesophago-gastric cancers. The most commonly reported late complications of minimally invasive oesophagectomy are anastamotic stricture, chylothorax, chronic diarrhoea and delayed gastric emptying. Symptomatic hiatus hernia presenting as a late complication of laparoscopic cardio-oesophagectomy is not a widely reported complication. We have encountered three such cases, two of which were treated laparoscopically.

It is accepted that the Advanced Trauma Life Support (ATLS) method, published by the American College of Surgeons, should be used in the initial assessment and management of the injured patient. It is recognised that mortality secondary to trauma follows a trimodal distribution. Catastrophic internal injuries cause death in seconds to minutes after injury, with other severe injuries often associated with significant blood loss, resulting in death minutes to hours later. The third peak is days to weeks later and is usually due to multi-organ failure. The quality of the management of the trauma patient in the first few hours following injury markedly affects the outcome. The ATLS protocol contains a primary and secondary survey, which provides a systematic way of identifying and treating injuries sustained. However there are circumstances when a potential threat to life may not easily be recognised. Most commonly errors occur in polytrauma patients when the secondary survey cannot be completed, due to primary survey findings requiring immediate intervention. Other factors that contribute to diagnostic errors are distracting injuries, where pain from one injury disguises another, or where the history is misleading or incomplete.

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. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment.Results: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003).Conclusion: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

Abstract The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.

Thermal ablation by use of radiofrequency energy can be used to achieve necrosis of liver tumours, and increased availability of this technique is leading to more widespread use. Much of the impetus for the use of radiofrequency ablation has come from cohort series that have provided an evidence base for this technique. Here, we give an overview of the current status of radiofrequency ablation for liver tumours, including its physical properties, to assess the characteristics that make this technique applicable in clinical practice. We review the technical development of probe design and summarise current indications and outcomes of reported clinical use. We also provide a profile of side-effects and information on the integration of this technique into the general management of patients with liver tumours. Current evidence suggests that radiofrequency ablation can be done with few side effects; however, although this technique seems to ablate tumours effectively, it should form part of multidisciplinary care for liver cancer. Crucially, the role of radiofrequency ablation in lengthening the survival of patients with liver tumours remains to be assessed.

BACKGROUND:Laparoscopic hernia repair excites controversy because its benefits are debatable and critics claim it is attended by serious complications. The one group of patients in whom benefits may outweigh the perceived disadvantages are those with bilateral or recurrent inguinal hernias.METHOD:One hundred twenty patients with bilateral or recurrent hernias were randomized to either laparoscopic transabdominal preperitoneal (TAPP) or open mesh repair. Patients completed a well-being questionnaire prior to and following surgery together with a visual analog pain score. Patients were followed up clinically at 1 and 3 months and thereafter by their general practitioner.RESULTS:Age and sex distribution was similar in the two groups. Laparoscopic TAPP hernia was quicker (40 vs 55 min; p < 0.001), less painful (visual analog pain score, 2.8 vs 4.3; p = 0.003) and allowed earlier return to work (11 vs 42 days; p < 0.001) compared to open mesh repair.CONCLUSION:This trial demonstrates that laparoscopic hernia repair via the TAPP route offers significant benefit to patients undergoing bilateral or recurrent inguinal hernia repair.

symptom questionnaire and were begun on Cisapride 20 mg p.o. b.i.d, p.r.n.Patients were followed monthly and satisfaction was accessed at each follow-up.Dissatisfied patients were advanced to Cisapride 20 mg b.i.d.plus Cimetidine 300 mg q.i.d. and if still symptomatic to Lansoprazole 30 mg q.d.Patients completing 12 months of the study were endoscoped and esophagitis was graded using the Savery-Miller classification.Results: The 51 patients who entered the study had the following clinical characteristics: their average age was 48 years (29-66 years) and 36% were male.Their severity score was 3.45 on a scale of 1-10 (10 = asymptomatic).76% had HB > 5 times per week while 72% had nocturnal HB2-5 times per week.On a monthly basis 92% had epigastric pain.78% had belching, 75% had early satiety, 74% had nausea.68% complained that symptoms interfered with daily activity.33 of the 51 patients have completed 12 months of the study.5 of these (15%) have developed grade 1-2 Savery-Miller esophagitis and I has developed short segment Barrett s esophagus over this time.Regarding medication usage, 70% (19/27) of patients with continuous NERD used Cisapride p.r.n.> 90% of the 12 months.11% (3/27) required Lansoprazole > 25% of the time.85% of these patients were satisfied with treatment> 80% of the 12 months.33% (2/6) of patients developing advanced GERD used Cisapride p.r.n.> 90% of the 12 months while 50% (3/6) required Lansoprazole > 25% of the time.66% of these patients were satisfied with treatment> 80% of the 12 months.Conclusions: I) NERD patients are highly symptomatic and perceive their symptoms as severe.2) 82% of NERD patients did not progress and the majority were satisfied with Cisapride 20 mg b.i.d.p.r.n. 3) 18% of patients developed advanced lesions over 12 months.They were more symptomatic and required more potent medication.

Background: Abdominal pain of uncertain aetiology (non-specific abdominal pain; NSAP) is the commonest reason for emergency surgical admission. The aim of this study was to examine the role of early laparoscopy in the management of NSAP.Methods: Some 120 patients, admitted between November 1995 and October 1998 with acute abdominal pain of uncertain aetiology, were randomized into two groups: group 1 had laparoscopy during the first 18 h of admission and group 2 had close observation, conventional investigation and surgical intervention if signs of peritonism developed. Outcome measures were diagnosis, operative procedures, duration of hospital stay, readmission rate, morbidity and death, patient satisfaction and total number of investigations performed.Results: Median hospital stay was 2 (range 1-13) days in both groups (P = 0.87). A diagnosis was established in 48 (81 per cent) of 59 patients in group I compared with 22 (36 per cent) of 61 in group 2 (P < 0.0001). The morbidity rate was 14 (24 per cent) of 59 in group 1 and 19 (31 per cent) of 61 in group 2 (P = 0.3629). The readmission rate at a median follow-up of 21 (range 1-35) months was 17 (29 per cent) of 59 in group 1 compared with 20 (33 per cent) of 61 in group 2 (P = 0.6375). Web-being scores improved from 134 on admission to 149 of 177 6 weeks later in group 1 (P = 0.007) and from 132 to 143 of 177 in group 2 (P = 0.089).Conclusion: Early laparoscopy provided a higher diagnostic accuracy and improved quality of life in patients with NSAP.