Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh a randomized controlled trial

Author version made available in accordance with pubilsher policy. 12 month embargo applies from the date of publication (1 Feb 2015).Objective: Determine whether absorbable or non-absorbable mesh in repair of large hiatus hernias reduces the risk of recurrence, compared to suture repair. Summary Background Data: Repair of large hiatus hernia is associated with radiological recurrence rates of up to 30%, and to improve outcomes mesh repair has been recommended. Previous trials have shown less short term recurrence with mesh, but adverse outcomes limit mesh use. Methods: Multicentre prospective double blind randomized controlled trial of 3 methods of repair; sutures vs. absorbable mesh vs. non-absorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 6 months. Secondary outcomes - clinical symptom scores at 1, 3, 6 and 12 months. Results: 126 patients enrolled - 43 sutures, 41 absorbable mesh and 42 non-absorbable mesh. 96.0% were followed to 12 months, with objective follow-up data in 92.9%. A recurrent hernia (any size) was identified in 23.1% following suture repair, 30.8% - absorbable mesh, and 12.8% - non-absorbable mesh (p=0.161). Clinical outcomes were similar, except less heartburn at 3 & 6 months and less bloating at 12 months with non-absorbable mesh, and more heartburn at 3 months, odynophagia at 1 month, nausea at 3 & 12 months, wheezing at 6 months, and inability to belch at 12 months following absorbable mesh. The magnitude of the clinical differences were small. Conclusions: No significant differences were seen for recurrent hiatus hernia, and the clinical differences were unlikely to be clinically significant. Overall outcomes following sutured repair were similar to mesh repair

Pre-therapy mRNA expression of TNF is associated with regimen-related gastrointestinal toxicity in patients with esophageal cancer: a pilot study

Author version made available following 12 month embargo from date of publication (27 March 2015) in accordance with publisher copyright policy.Purpose Esophageal cancer has a high mortality rate, and its multimodality treatment is often associated with significant rates of severe toxicity. Effort is needed to uncover ways to maximize effectiveness of therapy through identification of predictive markers of response and toxicity. As such, the aim of this study was to identify genes predictive of chemoradiotherapy-induced gastrointestinal toxicity using an immune pathway-targeted approach. Methods Adults with esophageal cancer treated with chemotherapy consisting of 5-fluorouracil and cisplatin and 45–50 Gy radiation were recruited to the study. Pre-therapy-collected whole blood was analyzed for relative expression of immune genes using real-time polymerase chain reaction (RT-PCR). Gene expression was compared between patients who experienced severe regimen-related gastrointestinal toxicity vs. those experiencing mild to moderate toxicity. Results Blood from 31 patients were analyzed by RT-PCR. Out of 84 immune genes investigated, TNF was significantly elevated (2.05-fold, p = 0.025) in the toxic group (n = 12) compared to the non-toxic group (n = 19). Nausea and vomiting was the most commonly documented severe toxicity. No associations between toxicity and response, age, sex, histology, or treatment were evident. Conclusions This study supports evidence of TNF as a predictive biomarker in regimen-related gastrointestinal toxicity. Confirming these findings in a larger cohort is warranted

Climate Change, Coral Reef Ecosystems, and Management Options for Marine Protected Areas

Marine protected areas (MPAs) provide place-based management of marine ecosystems through various degrees and types of protective actions. Habitats such as coral reefs are especially susceptible to degradation resulting from climate change, as evidenced by mass bleaching events over the past two decades. Marine ecosystems are being altered by direct effects of climate change including ocean warming, ocean acidification, rising sea level, changing circulation patterns, increasing severity of storms, and changing freshwater influxes. As impacts of climate change strengthen they may exacerbate effects of existing stressors and require new or modified management approaches; MPA networks are generally accepted as an improvement over individual MPAs to address multiple threats to the marine environment. While MPA networks are considered a potentially effective management approach for conserving marine biodiversity, they should be established in conjunction with other management strategies, such as fisheries regulations and reductions of nutrients and other forms of land-based pollution. Information about interactions between climate change and more “traditional” stressors is limited. MPA managers are faced with high levels of uncertainty about likely outcomes of management actions because climate change impacts have strong interactions with existing stressors, such as land-based sources of pollution, overfishing and destructive fishing practices, invasive species, and diseases. Management options include ameliorating existing stressors, protecting potentially resilient areas, developing networks of MPAs, and integrating climate change into MPA planning, management, and evaluation

Randomized trial of division versus nondivision of the short gastric vessels during laparoscopic nissen fundoplication: 10-year outcomes

Background: Although laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastroesophageal reflux, in some patients it is followed by troublesome side effects, such as dysphagia, abdominal bloating, and inability to belch. It has been claimed that dividing the short gastric blood vessels during laparoscopic Nissen fundoplication minimizes the risk of these problems. We have previously reported the 6-month and 5-year outcomes from a randomized trial, which have shown no advantages after division of these vessels. In this study, we determined the longer-term (10 years) outcomes from this trial. Methods: From May 1994 to October 1995, 102 patients with gastroesophageal reflux disease who underwent a laparoscopic Nissen fundoplication were entered into this randomized trial (vessels divided in 50, not divided in 52). At 10-year follow-up, 88 patients provided clinical follow-up information. Follow-up was obtained by telephone interview conducted by an independent and blinded investigator who applied a standardized questionnaire. Results: At 10-year follow-up no significant differences between the 2 groups could be identified. Heartburn, dysphagia, and overall satisfaction were similar for both study groups. Conclusions: The 10-year clinical outcomes from this trial have shown no benefit for division of the short gastric vessels during laparoscopic Nissen fundoplication.Huiqi Yang, David I. Watson, David I., Carolyn J. Lally, Peter G. Devitt, Philip A. Game and Glyn G. Jamieso

Division of Short Gastric Vessels at Laparoscopic Nissen Fundoplication: A Prospective Double-Blind Randomized Trial With 5-Year Follow-Up

OBJECTIVE: To determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients. SUMMARY BACKGROUND DATA: Dividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery. METHODS: Between May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator. RESULTS: There were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels. CONCLUSIONS: Division of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of “wind-related” problems

Estimating renal function in morbidly obese patients

BackgroundThis paper aims to evaluate, in a clinical context, current creatinine-based formulas commonly used to calculate renal function in morbidly obese patients.MethodsA retrospective analysis was performed of the estimates of renal function of 63 obese or morbidly obese patients undergoing gastric bypass surgery. Each patient's glomerular filtration rate (GFR) was calculated using five methods, both before and after surgery, and these approximations were then compared.ResultsPrior to surgery, the values offered by the five formulas for the renal function of this population ranged widely, by over a factor of 2. After surgery, the three weight-based GFR estimation methods indicated that a significant change in GFR had occurred, but the two non-weight-based formulas showed no significant change in estimated GFR.ConclusionsAt baseline and after significant weight loss, creatinine-based formulas differ twofold in their estimates of renal function of the morbidly obese. An accurate method for calculating these patients' renal function is required to improve patient safety with drug dosing as well as to ensure early detection of renal failure.Alex Lovell, Philip Game, Gary Wittert, Campbell Thompso