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ABSTRACT: UK guidelines recommend that patients with gallstone pancreatitis have cholecystectomy within 2 weeks of their pancreatitis. A proportion of these are elderly with significant comorbidities rendering them high risk for general anaesthesia and surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) may offer a safe alternative to cholecystectomy as definitive treatment in these patients.
A retrospective review of all cases of gallstone pancreatitis presenting between 1999 and 2009 was undertaken.
One hundred one patients underwent ERCP and ES as a definitive treatment for gallstone pancreatitis with a median age of 78 years (range, 43-96 years) and a median American Society of Anesthesiologists grade of 2. Three patients died from pancreatitis despite successful ERCP. Eighty-nine patients were successfully treated with an ERCP alone, and 84 patients (94%) had no recurrence of pancreatitis with a mean follow-up of 41 months (±32 months, range 4-118 months). The total patient follow-up was 3,260 months. Twenty-seven patients (33%) died within the follow-up period of unrelated causes, explaining the lower than expected median follow-up. Five patients had a recurrence of pancreatitis during follow-up (6%).
ERCP with ES is a safe alternative to laparoscopic cholecystectomy to prevent further attacks of gallstone pancreatitis in high-risk surgical patients and the elderly.
Journal of Gastrointestinal Surgery 12/2011; 15(12):2205-10. · 2.83 Impact Factor
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ABSTRACT: Advocates of single-port laparoscopic cholecystectomy (SPLC) claim that improved cosmetic outcome is one of its main benefits over conventional laparoscopic cholecystectomy (CLC). However, the published data quantifying the cosmetic outcome after CLC is sparse. This study aimed to determine the cosmetic outcome after CLC using a validated scar assessment tool.
The patient scar assessment questionnaire was sent to all women ages 20-50 years who had undergone CLC at the Norfolk and Norwich University Hospital (Norwich), the Homerton Hospital (London), and the Musgrove Park Hospital (Taunton) in 2005 (n = 380). In all cases, the operation had been performed using a four-port technique. The patients were asked to give scores related to the appearance and symptoms associated with the scars at the time the questionnaire was completed.
Of the 380 patients, 195 responded to the questionnaire, giving a response rate of 51%. The median age of the responders was 39 years, and 63 (32%) of them had undergone previous surgery. The mean score for each section was low, indicating a favorable cosmetic outcome. This correlated with the global question answered with "excellent" for 4 of 5 categories and "good" for the remaining category. Nine patients highlighted dissatisfaction with the umbilical incision.
Patients perceive the cosmetic results after CLC as excellent. Therefore, SPLC seems to have a limited role in terms of improving cosmesis for patients undergoing cholecystectomy. Anecdotal evidence from the questionnaire suggests that the umbilical port may be the site of problems for some patients. Further investigation is needed to determine whether this is significant, especially because it may be exaggerated after SPLC.
Surgical Endoscopy 03/2011; 25(8):2574-7. · 4.01 Impact Factor
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ABSTRACT: In this study we examine the importance of regular postoperative follow-up and the effect of geographical distance from the centre of follow-up on long-term weight loss after laparoscopic adjustable gastric banding (LAGB).
Between 1997 and 2009, 150 patients underwent LAGB. Postoperatively, patients were invited to attend a monthly nurse-led follow-up clinic to assess weight loss and make necessary band adjustments. Demographic data and weight loss at each follow-up appointment were prospectively entered into a database. Percent excess weight loss (%EWL), number of follow-ups per patient, and the distance each patient had to travel to the surgical centre were calculated.
One hundred thirty-seven females and 13 males with a median age of 45 years, median weight of 121 kg, and median BMI of 45 have had surgery to date. Median operative time was 35 min and median length of hospital stay was 1 night. Median %EWL at 1, 3, 6, 9, 12, 24, and 36 months postoperatively was 10, 17, 26, 37, 54, 64, and 76%, respectively. Median %EWL at 12 months after LABG grouped by 1-3, 4-6, 7-9, and more than 10 follow-up attendances was 41, 48, 54, and 69%, respectively. At a median of 12 months postoperatively, at 0-10, 10-20, 20-30, and more than 30 miles from the centre of follow-up, median %EWL was 54, 57, 52, and 49%, respectively, and median number of follow-up attendances at those distances was 10, 8, 5, and 5, respectively.
With good local follow-up, weight loss after LABG can rival that achieved with more invasive procedures. Follow-up is an important determinant for weight loss after LABG. Patients attend fewer follow-up clinics with increasing distance from the centre of follow-up.
Surgical Endoscopy 03/2010; 24(10):2432-8. · 4.01 Impact Factor
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Gastrointestinal endoscopy 11/2008; 69(1):156-8; discussion 158. · 6.71 Impact Factor
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ABSTRACT: Swedish adjustable gastric banding (SAGB) is a common weight loss procedure performed worldwide. The exact mechanism by which it achieves appetite suppression, and hence weight loss, is not clear. One possible mechanism is altered meal handling by the post-SAGB stomach.
Five post SAGB patients and five age/sex-matched controls were recruited. Pre- and post-meal magnetic resonance imaging (MRI) was performed with two liquid test meals of differing viscosity-locust bean gum (3.0%) and water. Appetite was assessed using ten-point visual analogue scales.
There were significant relationships between hunger scores and esophageal, pouch and residual stomach fluid volume changes for the locust bean gum meal (p=0.033, 0.043 and 0.011, respectively). The rate constants for gastric emptying were similar in the two groups for both the gum (0.038+/-0.016 min(-1) for SAGB, 0.041+/-0.032 min(-1) for controls, p=0.44) and water meals (0.068+/-0.044 min(-1) for SAGB, 0.044+/-0.009 min(-1) for controls, p=0.35). An unexpected finding was asymptomatic esophageal meal retention with the locust bean gum meal in the post-SAGB arm (mean 16.9 ml at 15 min).
There is no evidence of differences in volume-dependent gastric emptying between the normal and post-SAGB stomach. Further investigation of the phenomenon of esophageal retention, and its role in post-SAGB satiety, is warranted.
Obesity Surgery 07/2008; 19(6):757-63. · 3.29 Impact Factor
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ABSTRACT: Epidemiologic studies suggest a reduced risk of esophageal adenocarcinoma in populations with a high consumption of fish, and n-3 fatty acids inhibit experimental carcinogenesis. One possible explanation is the suppression of eicosanoid production through inhibition of cyclooxygenase 2 (COX-2).
The objective was to determine the effects of dietary supplementation with the n-3 fatty acid eicosapentaenoic acid (EPA) on a number of biological endpoints in Barrett's esophagus.
Fifty-two participants with known Barrett's esophagus underwent endoscopy. Biopsy samples were obtained from a recorded level within the area of Barrett's esophagus, and then 27 patients were randomly assigned to consume EPA capsules (1.5 g/d) for 6 mo or no supplement (controls). At the end of this period, patients again underwent endoscopy, and biopsy samples were collected at the same level. Tissue samples were analyzed for mucosal lipid, prostaglandin E2, leukotriene B4, COX-2 protein, and RNA concentrations. Cellular proliferation was also measured, by Ki-67 immunohistochemistry.
The EPA content of esophageal mucosa increased over the study period in the n-3-supplemented subjects and was significantly different from the content in the controls (P < 0.01). There was also a significant decline in COX-2 protein concentrations (measured by immunoblotting) in the n-3 group, and the difference was significant from that in the controls (P < 0.05); no difference in COX-2 RNA concentrations was observed between groups. This change in COX-2 protein was inversely related to the change in EPA content (P < 0.05). There was no significant difference in the change in prostaglandin E2, leukotriene B4, or cellular proliferation between the 2 groups.
Supplementation with EPA significantly changed n-3 fatty acid concentrations and reduced COX-2 concentrations in Barrett's tissue.
American Journal of Clinical Nutrition 04/2008; 87(4):949-56. · 6.67 Impact Factor
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ABSTRACT: Although laparoscopic appendicectomy has been performed since 1983, the optimal approach for appendicectomy is still under debate. A systematic review and meta-analysis of all randomized controlled trials between 1995 and 2006 was undertaken. Studies were analyzed overall and in 2 subgroups (pre-2000 and post-2000) to examine for changes in outcomes with increased laparoscopic experience. Operation time was significantly longer for laparoscopy and hospital stay was shorter. Operating time reduced markedly for laparoscopy on subgroup analysis. The risks of postoperative ileus and wound infection are lower for laparoscopy. Perhaps paradoxically, the risk of intra-abdominal abscess development is significantly raised with laparoscopy with an odds ratio of 2.26 (P=0.0002). Laparoscopic appendicectomy is a safe and effective method of treating acute appendicitis. This meta-analysis shows improvement in the outcomes of laparoscopy with increasing laparoscopic experience but open surgery appears to still confer benefits, especially in terms of intra-abdominal abscess incidence.
Surgical laparoscopy, endoscopy & percutaneous techniques 09/2007; 17(4):245-55. · 1.23 Impact Factor
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ABSTRACT: Clayman and associates first described laparoscopic nephrectomy in 1990. This paper describes the first randomized controlled trial to compare laparoscopic with open surgery for simple and radical nephrectomy.
Between 2001 and 2004, 45 patients requiring simple or radical nephrectomy (tumors as large as 8 cm) were randomized to either open surgery through a loin incision or laparoscopic nephrectomy (transperitoneal). Outcome measures included operative time, complications, hospital stay, pain scores, time to return to normal activities, and quality of life scores (EuroQol).
The mean operative time was 105 minutes in the laparoscopic group and 93 minutes in the open-surgery group (P = 0.4). Blood loss, complications, and the mortality rate were similar in the two groups, as was the hospital stay at a median of 4 days in the laparoscopic group and 5 days in the open group (P = 0.9). Postoperative visual analog pain scores averaged 3.6 in the laparoscopic group compared with 5.4 in the open group (P = 0.02). There was no difference in pain scores at 3 months. Return to normal activities was faster in the laparoscopic group at 42 days v 62 days in the open group (P = 0.04).
Laparoscopic nephrectomy is associated with less postoperative pain and a faster return to normal activities than open nephrectomy.
Journal of Endourology 07/2007; 21(6):610-3. · 1.85 Impact Factor
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ABSTRACT: The prevalence of morbid obesity in the UK population is rising, bringing with it increased levels of cardiovascular disease, diabetes, arthritis and early mortality. The overall cost to the health service is high, and is set to increase over the coming decades as the overweight population ages. Dietary, lifestyle and pharmacological interventions offer at best reasonable, short-term weight reduction and often fail. Surgical intervention is a safe and effective means of delivering marked long-term weight reduction. This article compares and contrasts the options available for surgical treatment of morbid obesity based on a review of the current literature.
Postgraduate medical journal 02/2007; 83(975):8-15. · 1.38 Impact Factor
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ABSTRACT: Many studies have confirmed the effectiveness of laparoscopic paraesophageal hernia repair, but there are reports of high recurrence rates after surgery. We have conducted a review of the literature to determine whether it is a safe and durable procedure. A literature search was performed to identify all papers relevant to laparoscopic paraesophageal hernia repair. Twenty studies met the inclusion criteria for this review. In total, 1415 patients underwent attempted repair (mean age 65.7 y) of which 94% underwent an antireflux procedure. There were 70 (5.3%) episodes of operative morbidity and 173 (12.7%) patients experienced postoperative complications. In 10 studies, radiologic follow-up was offered after a mean of 16.5 months. Of those undergoing contrast swallow 26.9% had evidence of anatomic recurrence. In conclusion, recurrence rates after laparoscopic repair seem to be high compared with earlier studies of open repair. The long-term consequences of anatomic recurrence are currently uncertain.
Surgical laparoscopy, endoscopy & percutaneous techniques 11/2006; 16(5):301-6. · 1.23 Impact Factor
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ABSTRACT: Laparoscopic Nissen fundoplication and proton pump inhibitor (PPI) therapy are both established treatments for gastroesophageal reflux disease (GERD). We have performed a prospective randomized study comparing these two treatments and now have long-term follow-up data. Between July 1997 and August 2001, 183 patients in Norwich took part in a randomized controlled trial comparing laparoscopic Nissen fundoplication and PPI therapy for the treatment of GERD. In October 2005, patients were followed up and asked to complete a reflux symptom questionnaire. Ninety-one patients were randomized to have surgery and 92 to have optimized PPI therapy. After 12 months, those who had been randomized to PPI were offered the opportunity to have surgery. Fifty-four patients went on to have antireflux surgery; the remaining 38 did not. In all three groups, there was a significant improvement in symptom score after the initial 12 months (P < 0.01; Mann-Whitney U test). However, those who later had surgery despite having had optimal PPI treatment beforehand experienced further symptomatic improvement (P < 0.01) at long-term follow-up (median 6.9 years, range, 4.3-8.3). Both optimal PPI therapy and laparoscopic Nissen fundoplication are effective treatments for GERD. However, surgery offers additional benefit for those who have only partial symptomatic relief whilst on PPIs.
Journal of Gastrointestinal Surgery 11/2006; 10(9):1312-6; discussion 1316-7. · 2.83 Impact Factor
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ABSTRACT: Intraperitoneal administration of local anesthesia is often used to improve pain relief after laparoscopic cholecystectomy. We have conducted a meta-analysis to establish the efficacy of this technique in reducing early postoperative abdominal pain. A systematic literature search revealed 24 randomized, controlled trials assessing intraperitoneal local anesthetic use in laparoscopic cholecystectomy that met inclusion criteria. Of these, 16 studies reported sufficient data to allow pooled quantitative analysis. The weighted mean differences (WMD) in visual analog pain score at 4 h after surgery were pooled using a random effects model. Overall, the use of intraperitoneal local anesthesia resulted in a significantly reduced pain score at 4 h (WMD, -9 mm; 95% confidence interval [CI], -13 to -5). Subgroup analysis suggested that the effect was greater when the local anesthetic was given at the start of the operation (WMD, -13 mm; 95% CI, -19 to -7) compared with instillation at the end (WMD, -6 mm; 95% CI, -10 to -2). No adverse events related to local anesthetic toxicity were reported. We conclude that the use of intraperitoneal local anesthesia is safe, and it results in a statistically significant reduction in early postoperative abdominal pain.
Anesthesia and analgesia 10/2006; 103(3):682-8. · 3.08 Impact Factor
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ABSTRACT: Adhesion formation is a long-term complication of laparoscopic inguinal hernia surgery-particularly by the transabdominal preperitoneal technique; but it is not thought to occur after open repair. We describe a gentleman presenting with a recurrent hernia who had previously undergone an open mesh plug repair 4 years earlier. At laparoscopy he was found to have considerable adhesions associated with the plug. These were successfully divided before repair. This case illustrates the possibility of intra-abdominal adhesions developing even after open hernia surgery.
Surgical laparoscopy, endoscopy & percutaneous techniques 07/2006; 16(3):172. · 1.23 Impact Factor
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ABSTRACT: Acute pancreatitis remains a common presentation to acute surgical units and carries significant morbidity and mortality. The progression of the disease to necrotizing pancreatitis and multi-organ dysfunction syndrome (MODS) is associated with a very poor clinical outcome, and persistently high mortality. Increases in serum endothelin (ET) have been seen in animal models of acute pancreatitis and this study aims to investigate whether there is a change in serum ET-1 in patients with acute pancreatitis and whether any such change is linked to disease severity.
All patients admitted with acute pancreatitis were prospectively recruited from the emergency admissions at the Norfolk and Norwich University Hospital. Serum ET levels were determined on admission, at 24 hours and 5 days post admission. Healthy adult controls were recruited from dermatology outpatients.
A total of 21 patients joined the trial after giving informed consent. There were 3 men and 18 women with a median age of 65 years (range 26-87 years). Serum ET levels were significantly higher in acute pancreatitis patients than in normal controls (P<0.05). An association was seen between persistently raised serum ET levels and progression to MODS.
The study does demonstrate a correlation between the circulating levels of ET and acute pancreatitis in humans, although it does not elicit its involvement in the pathogenesis of the disease. The observation that a persistently high level of circulating ET-1 is associated with progression to MODS may indicate a role for ET in the monitoring of acute pancreatitis patients for recovery or progression to MODS.
Hepatobiliary & pancreatic diseases international: HBPD INT 06/2006; 5(2):290-3. · 1.08 Impact Factor
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BMJ (Clinical research ed.). 02/2006; 332(7535):236.
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ABSTRACT: The incidence of oesophageal cancer has doubled in the last three decades. Non-steroidal anti-inflammatory drugs (NSAIDs) may be protective, whilst bronchodilators and calcium channel blockers that relax the lower oesophageal sphincter (LOS) may increase gastro-oesophageal reflux and the risk of oesophageal adenocarcinoma. We conducted a case-control study to examine the association between the use of NSAIDs and drugs which relax the LOS and the risk of oesophageal cancer.
In Norfolk, 411 patients with a primary neoplasm of the oesophagus or cardia were matched with 1,644 controls with non-melanotic skin lesions. Data on the use of NSAIDs, bronchodilators and calcium channel blockers was collected.
Intake of NSAIDs was less in cases of oesophageal cancer as compared to the control group. The odds ratios (OR) and 95% confidence intervals (CI) for different NSAIDs were as follows: aspirin 0.35 (0.24-0.51); other NSAIDs 0.25 (0.16-0.40), and Cox-2 inhibitors 0.46 (0.20-0.94). LOS-relaxing drugs were consumed more frequently in cases of oesophageal cancer as compared to the controls. The OR for LOS-relaxing drugs was: inhaled bronchodilators 3.2 (95% CI 2.2-4.7); theophylline 1.9 (95% CI 1.3-5.1), and calcium channel blockers 2.4 (95% CI 1.2-5.0).
Within the limitations of a case-control study using patients with non-melanotic skin lesions as controls, our results are consistent with the hypothesis that oesophageal cancer has a negative association with NSAID use, and a positive association with drugs that relax the LOS.
Digestion 02/2006; 74(2):109-15. · 2.05 Impact Factor
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ABSTRACT: Laparoscopic surgery is arguably the treatment of choice for patients undergoing elective splenectomy; however, for those patients with massive splenomegaly, laparoscopic surgery may prove difficult.
6 years' experience of elective splenectomy was reviewed, in particular looking at the outcome of laparoscopic splenectomy in relation to the degree of splenomegaly.
The conversion rate for laparoscopic splenectomy on patients with spleens weighing less than 1 kg was 0% whereas the conversion rate for those with spleens weighing more than 1 kg was 60%. In addition, a good correlation between both operative time and intra-operative blood loss in relation to splenic weight was observed. Open splenectomy on patients with spleens weighing more than 1 kg reduced the operative time and intra-operative blood loss without affecting hospital stay.
Laparoscopic splenectomy is the method of choice for elective splenectomy in patients with splenic weight estimated to be < 1 kg; however, the operation takes longer, there is a high risk of conversion and there is an increase in blood loss/morbidity associated with massive splenomegaly (spleen > 1 kg) if splenectomy is attempted laparoscopically.
Annals of The Royal College of Surgeons of England 08/2003; 85(4):248-51. · 1.23 Impact Factor
