Sylvester O'Halloran Surgical Scientific Meeting - IJMS | Irish Journal ...

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SESSION THREE ONE
SYLVESTER O’HALLORAN SURGICAL SCIENTIFIC MEETING • 4 - 5 MARCH 2005 • JEAN MONNET THEATRE, UNIVERSITY OF LIMERICK
SYLVESTER O’HALLORAN SURGICAL SCIENTIFIC MEETING • 4 - 5 MARCH 2005 • JEAN MONNET THEATRE, UNIVERSITY OF LIMERICK
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SESSION
SESSION THREE ONE
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Prospective trial comparing contrast swallow, CT
scanning and endoscopy in the diagnosis of anastomotic
leak following upper digestive tract surgery
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Anastomotic leaks following
gastro-oesophageal surgery are
not uncommon. The identification
and assessment of severity can be
challenging with contrast swallow
radiology.
Routine studies fail to identify clinically
significant anastomotic leaks as well as
demonstrating non-significant leaks in
asymptomatic patients. We conducted a
prospective trial comparing contrast swallow
radiography, contrast enhanced computed
tomography (CT) scanning and endoscopy
in patients undergoing gastro-oesophageal
resection to determine the optimal method
of investigating anastomotic leak in the postoperative
period. Thirty-two patients were
studied following oesophagectomy (n=24)
and gastrectomy (N=8) in a prospective,
non-randomised trial. All patients underwent
contrast swallow and CT scanning on day
seven post-operatively followed by endoscopy
on day eight. The radiologist and endoscopist
were blinded to their respective findings
which were recorded independently on
the database. Thirty patients underwent
all three studies. Four anastomotic leaks
were identified. Both symptomatic leaks
were identified on endoscopy. Only one of
these was noted on Day Seven radiology.
Two asymptomatic anastomotic defects
were identified on endoscopy alone. These
patients recovered fully with conservative
therapy. Two patients were deemed too
unfit to undergo endoscopy given their
poor performance status. Contrast swallow
demonstrated one false (pseudo) leak which
was outruled definitively by CT scanning and
endoscopy. Results suggest that endoscopy
is the preferred method of assessment of
anastomotic integrity in patients undergoing
oesophagogastric resection. Contrast swallow
and CT scanning are less accurate. We would
advocate the use of selective endoscopy in
those with clinical suspicion of leak.
Long term follow-up of patients undergoing
anti-reflux surgery
Many studies show excellent
short to medium term results
following Laparoscopic Nissen
fundoplication. Few consider
outcome more than five years
post-operatively.
The aim was to evaluate long-term patient
satisfaction and durability of Laparoscopic
Nissen fundoplication. All patients
who underwent Laparoscopic Nissen
fundoplication from September 1993 to
December 1998 were included. An outcome
questionnaire was constructed based on
previously validated questionnaires. Patients
were telephoned between February and
May 2004. During the study period 133
patients underwent Laparoscopic Nissen
fundoplication. Male to female ratio was 1.4:1,
mean age 42.3 years (range 12 - 77 years), and
mean follow-up 94 months (range 62 - 128
months). One hundred and eight patients
(81.2%) responded to the questionnaire.
Eight patients had recurrence of symptoms
at a mean of 42 months post fundoplication
(range 2 to 72 months). Seventy-five percent
of recurrences offered more than three
years post fundoplication. In three of the
eight patients (37.5%) recurrence was more
than five years post fundoplication. Four
D Broe, BA Hogan,
DC Winter, CG Murphy,
MJ Lee, PJ Broe
Depts. of Surgery and
Radiology, Beaumont
Hospital, Beaumont,
Dublin
PA Sloane, J Dowdall,
S Roche, MF Khan,
OJ McAnena
Dept. of General Surgery,
University College
Hospital, Galway
Current Address of First
Author: Regenerative
Medicine Institute, NCBES,
National University of
Ireland, Galway
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underwent refundoplication at a mean of
54.25 months after original surgery (range 12
to 86 months). Outcome was rated as cure
or excellent by 101 patients (93.5%), including
all four patients who had refundoplication.
Seven patients (6.5%) rated outcome as
failure, four because of symptom recurrence
and three because of wrap take down.
Laparoscopic Nissen fundoplication results
in a high degree of patient satisfaction.
A significant proportion of symptom
recurrences occur late. Short to medium
term follow-up studies do not identify these
patients. This needs to be considered when
evaluating their outcome.
Boerhaave’s syndrome: fourteen cases of spontaneous
oesophageal rupture with varying management
strategies in a single centre
Spontaneous oesophageal rupture,
also known as Boerhaave’s
syndrome, is rare and carries a high
associated morbidity and mortality.
Individual surgical experience
with this condition remains low
and therefore the management of
Boerhaave’s remains controversial.
Methods
A retrospective review of cases presenting
to St. James’s hospital, as a tertiary referral
centre, over a period of eight years was
reviewed. Perforations were excluded if
iatrogenic or secondary to underlying
oesophageal disease.
Results
A total of fourteen patients were identified.
There were eleven men and three women,
whose ages ranged from 39 to 75 years.
Eight patients were managed operatively
while six were managed conservatively.
Diagnosis was based on clinical history
and examination, oesophageal contrast
swallow and CT scanning. Seven patients
underwent thoracotomy with primary closure
of the oesophageal perforation and tissue
reinforcement. One patient underwent
oesophagogastrectomy. Mean post-operative
stay was 39 days with a mean ICU stay of 7.5
days. A covered stent was placed at OGD in
two patients who were treated conservatively.
Mean in-patient stay for those managed nonoperatively
was 61 days with 18.2 days in ICU.
Mortality was identical in both groups (n=1).
Morbidity was slightly higher in the group
treated conservatively (n=4/6) compared to
surgical intervention (n=5/8)
Conclusions
Surgical intervention remains the gold
standard for cases which are diagnosed
promptly. Where the diagnosis is delayed
utilization of covered oesophageal stents
is a viable option. In single institutions,
management strategies can be customised,
thus reducing overall mortality.
RS Prichard, J Butt,
N Al-Sarraf, S Frolich,
B Manning, N Ravi,
JV Reynolds
Upper Gastrointestinal
Surgical Professorial
Unit, St. James’s Hospital,
James’s Street, Dublin
32 Pulmonary emboli in the surgical community R FitzGerald, S Rajendran,
Despite significant advances in the
prevention and treatment of venous
thromboembolism, pulmonary embolism
remains the most common
preventable cause of hospital death.
It is imperative, thus, to identify at risk-patient
groups who would benefit from higher dose
thromboprophylaxis in an attempt to decrease
morbidity and mortality from this condition.
We performed a retrospective study of
all patients admitted to Wexford General
C Canning, Z Martin,
D Beddy, JB O’Mahony,
K Mealy, D Evoy
Dept. of Surgery, Wexford
General Hospital, Wexford
36 IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 174 • NUMBER 1 • SUPPLEMENT 1
IRISH JOURNAL OF MEDICAL SCIENCE • VOLUME 174 • NUMBER 1 • SUPPLEMENT 1 37