Case Report Association between Oesophageal Diverticula and Leiomyomas: A Report of Two Cases

We report two rare cases of female patients presenting with oesophageal leiomyoma associated with oesophageal diverticulum, both of whom were surgically managed. Oesophageal leiomyoma and oesophageal diverticulum are uncommon as separate entities and rare as combined disease presentation. Clinicians need to be aware of the rare combination of the two entities and need to be able to exclude the presence of a tumour (benign or malignant) within a diverticulum and so plan the optimum treatment. Herein, we present two cases of oesophageal leiomyoma within oesophageal diverticulum and we try to elucidate the association between the two. To date, there is no consensus whether a diverticulum is secondary to a leiomyoma or, on the contrary, a leiomyoma arises within a diverticulum

The stem cell organisation, and the proliferative and gene expression profile of Barrett's epithelium, replicates pyloric-type gastric glands

Objective: Barrett's oesophagus shows appearances described as ‘intestinal metaplasia’, in structures called ‘crypts’ but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands. Methods: Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry. Results: Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell. Conclusions: Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Association between Oesophageal Diverticula and Leiomyomas: A Report of Two Cases

We report two rare cases of female patients presenting with oesophageal leiomyoma associated with oesophageal diverticulum, both of whom were surgically managed. Oesophageal leiomyoma and oesophageal diverticulum are uncommon as separate entities and rare as combined disease presentation. Clinicians need to be aware of the rare combination of the two entities and need to be able to exclude the presence of a tumour (benign or malignant) within a diverticulum and so plan the optimum treatment. Herein, we present two cases of oesophageal leiomyoma within oesophageal diverticulum and we try to elucidate the association between the two. To date, there is no consensus whether a diverticulum is secondary to a leiomyoma or, on the contrary, a leiomyoma arises within a diverticulum

Factors Affecting Patient Outcome, Following Surgical Insertion of Gastric Electrical Stimulator for Gastroparesis – 10 Year Experience in a Single UK Centre

Background: Drug refractory gastroparesis is a debilitating disorder associated with severe nausea and vomiting, resulting in a negative impact on quality of life. High frequency gastric electrical stimulation (GES) is a viable, alternative treatment with a reported success rate of between 50 and 70%. This study looks at the factors affecting outcome that may help in improved patient selection. Patients and Methods: Clinical data from 48 patients with severe, intractable gastroparesis, (12 diabetic and 36 idiopathic) were studied. The median age of the patient group was 36 years (range 15-80). There were 38 females (79%). GES was inserted via an open technique in 30 cases (62%) and by conventional, or robotic assisted laparoscopic technique, in 18 cases. A history of preoperative use of opioids for severe abdominal pain was noted in 18 patients (37.5%). Outcome was measured by changes in quality of life and severity of symptoms (QOL/SF-36 and TSS-total symptoms score). Fisher's exact test was used to analyze the association between patient-related factors and outcomes. Results: 36 out of 48 patients (76.6%) had significant improvement in TSS, especially in nausea and vomiting (>80% reduction) and QOL after GES insertion at follow-up. There was no significant, statistical difference between long-term outcomes in aetiology, age, sex of the patient or surgical technique (p= n.s.). However, patients who were not on opiates prior to surgery had significantly better long-term outcomes than those on opiates (p= 0.0018). Conclusion: Our study demonstrates that GES is effective in patients with drug refractory gastroparesis. However, patients on opiates prior to surgery do less well following GES. GES therefore, appears to be more effective in patients who have nausea and vomiting as the predominant symptoms than those with abdominal pai

Methylene Blue (MB) Test Versus Contrast Study (CS) in the Detection of Anastomotic Leak Following Oesogephactomy: A Prospective Study of 58 Patients

Background: Drug refractory gastroparesis is a debilitating disorder associated with severe nausea and vomiting, resulting in a negative impact on quality of life. High frequency gastric electrical stimulation (GES) is a viable, alternative treatment with a reported success rate of between 50 and 70%. This study looks at the factors affecting outcome that may help in improved patient selection. Patients and Methods: Clinical data from 48 patients with severe, intractable gastroparesis, (12 diabetic and 36 idiopathic) were studied. The median age of the patient group was 36 years (range 15-80). There were 38 females (79%). GES was inserted via an open technique in 30 cases (62%) and by conventional, or robotic assisted laparoscopic technique, in 18 cases. A history of preoperative use of opioids for severe abdominal pain was noted in 18 patients (37.5%). Outcome was measured by changes in quality of life and severity of symptoms (QOL/SF-36 and TSS-total symptoms score). Fisher's exact test was used to analyze the association between patient-related factors and outcomes. Results: 36 out of 48 patients (76.6%) had significant improvement in TSS, especially in nausea and vomiting (>80% reduction) and QOL after GES insertion at follow-up. There was no significant, statistical difference between long-term outcomes in aetiology, age, sex of the patient or surgical technique (p= n.s.). However, patients who were not on opiates prior to surgery had significantly better long-term outcomes than those on opiates (p= 0.0018). Conclusion: Our study demonstrates that GES is effective in patients with drug refractory gastroparesis. However, patients on opiates prior to surgery do less well following GES. GES therefore, appears to be more effective in patients who have nausea and vomiting as the predominant symptoms than those with abdominal pain