Accuracy of hiatal hernia diagnosis in bariatric patients : preoperative endoscopy versus intraoperative reference

Background and Aim: Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis. Methods: This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high-volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated. Results: A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m2 . Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80–88.23%) and specificity 91.44% (88.24–94.00%). Positive likelihood ratio was 8.53 (6.11–12.79) and negative likelihood ratio 0.27 (0.15–0.47). Positive predictive value was 45.16% (36.27–54.38%) and negative predictive value 97.58% (95.80–98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89–92.74%). Conclusion: Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard

Fast-track ambulatory abscess pathway : an Australian streamlined emergency surgery pathway

Background: Superficial skin abscesses account for a significant burden of emergency surgical admissions. The aim of this study was to evaluate the effectiveness of an ambulatory care pathway for emergently treating abscesses of the body requiring operative drainage. Method: A retrospective study of a prospective patient database was performed, using randomized patient selection. Patient demographics, length and cost of stay were compared between patients undergoing operative management for skin abscess before and after the implementation of the fast-track ambulatory abscess pathway (FAAP). Results: In total, 100 patients were analysed with 50 in the pre-ambulatory care pathway group and 50 in the FAAP group. The pre-ambulatory care pathway group had a mean age of 37.7 ± 15.8 years versus FAAP group of 35.3 ± 14.5 years. Total length of stay for the group was 85 versus 17 days with a mean comparison of 1.7 days versus 0.34 days (P < 0.001). This translated into a total cost saving of $74 100 in the FAAP group, with a mean comparison cost between the groups of$2884 versus $1402 (P < 0.001). Both reductions in length of stay and cost of stay were statistically significant after implementation of the pathway. Conclusion: This is the first Australian study to report the findings from an ambulatory care pathway for an emergency surgical intervention. We have shown that skin abscesses presenting through emergency can be managed as a day-case procedure, thereby decreasing these patients' overall length and cost of stay

Developing a self-reported tool on fall risk based on toileting responses on in-hospital falls

The aim of this cohort study was to determine the predictive value of a 2-item self-reported questionnaire regarding in-hospital toileting behavior for predicting falls in older inpatients and to compare its performance with an existing state-based falls assessment scale. Between May 28, 2009 and January 30, 2010, we assessed aged care inpatients for risk of falls using the standard STRATIFY fall screening tool and the 2-item self-reported questionnaire developed for this study. The participants were then followed up, with the primary outcome being the occurrence of falls. Results indicated that participants who were unable to answer the 2-item questionnaire appropriately or sensibly were 14.1 times (confidence interval [CI]: 4.4-45, p < 001) to 17.0 times (CI: 6.7-43, p<.001) more likely to fall than those who gave an appropriate negative or positive answer. Participants who were assessed to be at high risk of falls on the STRATIFY scale were 9.5 times (odds ratio: 9.5, CI: 1.3-72, p= .03) more likely to fall than those who were low risk. In conclusion, a simple bedside questionnaire regarding patients' toileting behavior with a careful appraisal of answers for appropriate and inappropriate answers may be used as a quick screening tool of fall risk

Impact of cytoreductive surgery and HIPEC on intraoperative gastrointestinal wall thickness and patient outcomes

Background: Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is associated with significant postoperative ileus (POI). This study examined intraoperative gastrointestinal wall thickness (GWT) and its association with patient outcomes. Patients and Methods: A prospective study of patients undergoing CRS and HIPEC. Proximal and distal small intestine GWT, before and after HIPEC were recorded. Results: Thirty-four patients (mean age=56.1 years, 61.8% female) were recruited. After HIPEC, the mean proximal (4.5 vs. 3.0 mm, p=0.03) and distal (4.3 vs. 3.4 mm, p<0.01) GWT were increased. Increased GWT was associated with prolonged operative time (10 vs. 8.5 h, p=0.03) and total length of stay (35.71 vs. 21.25 days, p=0.02). Postoperative ileus occurred in 23.5% of patients but differences between GWT groups did not reach significance (28.6% vs. 20%, p=0.56). Conclusion: GWT increased significantly during CRS and HIPEC and is reflective of tissue trauma and oedema. This was associated with prolonged operative time, total length of stay and post-operative ileus

Minimally invasive Venetian blinds ventral hernia repair with botulinum toxin chemical component separation

Background: Laparoscopic ventral repair is safe, with lower wound infection rates compared with open repair. ‘Venetian blinds’ technique of plication in combination with mesh reinforcement, is totally intra‐corporeal, with hernia defect and sac plication to reduce seroma formation. While laparoscopic suturing of the abdominal wall can represent a technical challenge, pre‐operative botulinum toxin A (BTA) injections as an adjunct can assist. This study aims to demonstrate feasibility and efficacy of this technique in abdominal wall hernia repair, with BTA adjunct in midline hernias. Methods: A single‐centre case series was conducted using minimally invasive ‘Venetian blinds’ technique for repair of complex ventral abdominal hernias. Twelve patients (seven midline, five non‐midline) underwent repair (11 laparoscopic; one robotic). Midline hernias received BTA (200–300 units Botox) 4–6 weeks prior to surgery. Repairs were mesh‐reinforced following fascial closure. Results: Twelve (10 female, two male) patients, with a median age 72 years (range 31–83) and body mass index of 27.3 kg/m2 (range 22.8–61.7) were included. The median length of operation was 133 min (range 45–290) and length of hospital stay 3 days (range 1–28). To date there has been no recurrence of hernia. A single symptomatic seroma was treated with antibiotics and did not require mesh removal. One patient developed hospital‐acquired pneumonia and pseudomembranous colitis. Conclusion: Minimally invasive ‘Venetian blinds’ technique has promising early results with both midline and non‐midline ventral hernias. The addition of BTA is a novel and feasible combination for repair of midline ventral hernias