Painless Obstructive Jaundice Secondary to a Common Bile Duct Abscess: A Delayed Sequela of Cholecystectomy

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature

Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials.

This item is under embargo for a period of 12 months from the date of publication, in accordance with the publisher's policy.Objective: To compare short and longer-term outcome after laparoscopic anterior 180˚ fundoplication (180˚ LAF) versus laparoscopic Nissen fundoplication (LNF). Summary of background data: LNF is currently the most frequently performed surgical therapy for GORD. Alternatively, 180˚ LAF has been alleged to reduce troublesome dysphagia and gas-related symptoms, with similar reflux control. Methods: MEDLINE, EMBASE, Cochrane Library and ISI web of Knowledge CPCI-S were searched for randomized clinical trials (RCTs) comparing primary 180˚ LAF versus LNF. The methodological quality was evaluated to assess bias risk. Primary outcomes were esophageal acid exposure, esophagitis, heartburn score, dilatation for dysphagia, modified Dakkak dysphagia score [0-45] and reoperation rate. Meta-analysis was conducted at one and five years. Results: Five distinct RCTs comparing 180˚ LAF (n=227) versus LNF (n=231) were identified. At one year, the Dakkak dysphagia score (2.8 vs 4.8; weighted mean difference (WMD) -2.25; 95% CI [-2.66, -1.83]; P<0.001), gas bloating (11% vs 18%; relative risk (RR) 0.59; 95% CI [0.36,0.97]; P=0.04), flatulence (14% vs 25%; RR 0.57; 95% CI [0.35,0.91]; P=0.02), inability to belch (19% vs 31%; RR0.63 ;95% CI [0.40,0.99]; P=0.05) and inability to relieve bloating (34% vs 44%; RR 0.74; 95% CI [0.55,0.99]; P=0.04) were lower after 180˚ LAF. Esophageal acid exposure (standardized mean difference (SMD) 0.19; 95% CI [-0.07,0.46]; P=0.15), esophagitis (19% vs 13%; RR 1.42; 95% CI [0.69, 2.91]; P=0.34), heartburn score (SMD 1.27; 95% CI [-0.36,2.90]; P=0.13), dilatation rate (1.4% vs 2.8%; RR 0.60; 95% CI [0.19,1.91]; P=0.39), reoperation rate (5.7% vs 2.8%; RR 2.08; 95% CI [0.80,5.41]; P=0.13), perioperative outcome, regurgitation, PPI use, LES pressure and patient satisfaction were similar after 180˚ LAF and LNF. At 5 years, the Dakkak dysphagia score, flatulence, inability to belch and inability to relieve bloating remained lower after 180˚ LAF. The five-year heartburn score, dilatation rate, reoperation rate, PPI use and patient satisfaction were similar. Conclusions: At one and five years, dysphagia and gas-related symptoms are lower after 180˚ LAF compared with LNF, and esophageal acid exposure and esophagitis are similar, with no differences in heartburn scores, patient satisfaction, dilatations and reoperation rate. These results lend level 1a support for the use of 180˚ LAF for the surgical treatment of GERD

α-Conotoxin Vc1.1 inhibits human dorsal root ganglion neuroexcitability and mouse colonic nociception via GABA\u3csub\u3eB\u3c/sub\u3e receptors

Objective α-Conotoxin Vc1.1 is a small disulfidebonded peptide from the venom of the marine cone snail Conus victoriae. Vc1.1 has antinociceptive actions in animal models of neuropathic pain, but its applicability to inhibiting human dorsal root ganglion (DRG) neuroexcitability and reducing chronic visceral pain (CVP) is unknown. Design We determined the inhibitory actions of Vc1.1 on human DRG neurons and on mouse colonic sensory afferents in healthy and chronic visceral hypersensitivity (CVH) states. In mice, visceral nociception was assessed by neuronal activation within the spinal cord in response to noxious colorectal distension (CRD). Quantitativereverse- transcription-PCR, single-cell-reversetranscription- PCR and immunohistochemistry determined ?-aminobutyric acid receptor B (GABABR) and voltagegated calcium channel (CaV2.2, CaV2.3) expression in human and mouse DRG neurons. Results Vc1.1 reduced the excitability of human DRG neurons, whereas a synthetic Vc1.1 analogue that is inactive at GABABR did not. Human DRG neurons expressed GABABR and its downstream effector channels CaV2.2 and CaV2.3. Mouse colonic DRG neurons exhibited high GABABR, CaV2.2 and CaV2.3 expression, with upregulation of the CaV2.2 exon-37a variant during CVH. Vc1.1 inhibited mouse colonic afferents ex vivo and nociceptive signalling of noxious CRD into the spinal cord in vivo, with greatest efficacy observed during CVH. A selective GABABR antagonist prevented Vc1.1-induced inhibition, whereas blocking both CaV2.2 and CaV2.3 caused inhibition comparable with Vc1.1 alone. Conclusions Vc1.1-mediated activation of GABABR is a novel mechanism for reducing the excitability of human DRG neurons. Vc1.1-induced activation of GABABR on the peripheral endings of colonic afferents reduces nociceptive signalling. The enhanced antinociceptive actions of Vc1.1 during CVH suggest it is a novel candidate for the treatment for CVP

Impact of the Mt. Pinatubo volcaniceruption on the lower ionosphere andatmospheric waves over Central Europe

The very strong volcanic eruption of Mt. Pinatubo in June 1991 directly affected the troposphere and lower and middle stratosphere. Here we look at its effects in the mesopause region as revealed by the radio wave absorption measurements in the lower ionosphere over Central Europe and inferred planetary and gravity wave activity. The gravity wave activity inferred from the nighttime LF radio wave absorption displays an evident enhancement for waves of periods of about 2-3 h coinciding with regional measurements of the optical depth of (volcanic) aerosols, while there is no detectable effect for short period waves (T < 1 h). There is no detectable effect in the planetary wave activity inferred from the daytime HF radio wave absorption. As for the absorption itself, the results on the impact of the Mt. Pinatubo eruption do not provide an observable effect

Impact of Climate Change on Surgery: A Scoping Review to Define Existing Knowledge and Identify Gaps

With climate change accelerated at a worrisome rate, global warming also will have implications for surgery and surgical practice. The goal of this current study was to systematically survey the literature and better understand how climate change has affected surgical disease burden, surgical care delivery, and surgical outcomes. We performed a comprehensive scoping review, screening 3334 unique citations from three databases – 1766 from Embase, 1329 from Pubmed and 239 from Scopus – to identify studies that had associated climate change with surgery. After systematic searching, quality appraisal, and data extraction, we synthesized findings from qualitative and quantitative studies. Twenty-six studies that met the inclusion criteria were included in the review. The studies associating climate change with surgery spanned all surgical subspecialties, although most notable examples came from urology, trauma surgery, and burns and reconstructive surgery. Although there is increasingly strong evidence for how climate change might affect surgery, there is a paucity of research attempting to establish a more direct correlation or causal link between the two. Additionally, we identified several studies that did not directly address climate change but instead focused on chronobiology and its effects on surgery, highlighting directions for future research. The existing evidence, despite its limitations, generates hypotheses for future work, implicating climate change as an independent contributor towards increased surgical disease burden, decreased surgical care delivery, and worsened surgical outcomes

Staging of colorectal cancer using lipid biomarkers and machine learning

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. Alteration in lipid metabolism and chemokine expression are considered hallmark characteristics of malignant progression and metastasis of CRC. Validated diagnostic and prognostic biomarkers are urgently needed to define molecular heterogeneous CRC clinical stages and subtypes, as liver dominant metastasis has poor survival outcomes. The aim of this study was to integrate lipid changes, concentrations of chemokines, such as platelet factor 4 and interleukin 8, and gene marker status measured in plasma samples, with clinical features from patients at different CRC stages or who had progressed to stage-IV colorectal liver metastasis (CLM). High-resolution liquid chromatography-mass spectrometry (HR-LC-MS) was used to determine the levels of candidate lipid biomarkers in each CRC patient's preoperative plasma samples and combined with chemokine, gene and clinical data. Machine learning models were then trained using known clinical outcomes to select biomarker combinations that best classify CRC stage and group. Bayesian neural net and multilinear regression-machine learning identified candidate biomarkers that classify CRC (stages I-III), CLM patients and control subjects (cancer-free or patients with polyps/diverticulitis), showing that integrating specific lipid signatures and chemokines (platelet factor-4 and interluken-8; IL-8) can improve prognostic accuracy. Gene marker status could contribute to disease prediction, but requires ubiquitous testing in clinical cohorts. Our findings demonstrate that correlating multiple disease related features with lipid changes could improve CRC prognosis. The identified signatures could be used as reference biomarkers to predict CRC prognosis and classify stages, and monitor therapeutic intervention

Electrolytic ablation of the rat pancreas: a feasibility trial

BACKGROUND: Pancreatic cancer is a biologically aggressive disease with less than 20% of patients suitable for a "curative" surgical resection. This, combined with the poor 5-year survival indicates that effective palliative methods for symptom relief are required. Currently there are no ablative techniques to treat pancreatic cancer in clinical use. Tissue electrolysis is the delivery of a direct current between an anode and cathode to induce localised necrosis. Electrolysis has been shown to be safe and reliable in producing hepatic tissue and tumour ablation in animal models and in a limited number of patients. This study investigates the feasibility of using electrolysis to produce localised pancreatic necrosis in a healthy rat model. METHOD: Ten rats were studied in total. Eight rats were treated with variable "doses" of coulombs, and the systemic and local effects were assessed; 2 rats were used as controls. RESULTS: Seven rats tolerated the procedure well without morbidity or mortality, and one died immediately post procedure. One control rat died on induction of anaesthesia. Serum amylase and glucose were not significantly affected. CONCLUSION: Electrolysis in the rat pancreas produced localised necrosis and appears both safe, and reproducible. This novel technique could offer significant advantages for patients with unresectable pancreatic tumours. The next stage of the study is to assess pancreatic electrolysis in a pig model, prior to human pilot studies

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Development of clinical-quality registries in Australia: the way forward

Guy J Maddern, Julian A Smith, Wendy Babidge and Gordon S Gu

Laparoscopic mesh measurement

C.I. Lauder, A. Strickland, G.J. Maddernhttp://www.ncbi.nlm.nih.gov/pubmed/2042589