Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life-threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70-85); mean American Society of Anesthesiologists class was 2.7 (range 1-3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30-day mortality, and median hospital stay was 3 days (range 2-14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.
Background: Primary Hodgkin's disease of the stomach is an extremely rare entity. Nearly all cases of primary gastric lymphoma are of the non-Hodgkin's variety. Diagnoses in such cases are difficult due to considerable histological similarities between the 2 disease entities.
SummaryA 35-year-old woman collapsed 18 hours after undergoing abdominal wall liposuction. Abdominal CT scan revealed a punctured spleen. She underwent an emergency splenectomy and made an uneventful recovery. Case reportA 35-year-old woman presented to plastic surgeons with increased adiposity in the lower trunk and upper thigh. She did not have any significant past medical or surgical history and was not taking any regular medications. Her preoperative haemoglobin level was 11.2 g/dL. She underwent abdominal wall and upper thigh tumescent liposuction through suprapubic and lateral abdominal wall stab incisions under general anaesthetic. She made an uneventful initial recovery from the anaesthetic and slept pain-free throughout the first night. Sixteen hours hours after surgery she complained of acute onset of severe generalized abdominal pain and abdominal distension and collapsed. On examination she had marked pallor and class II hypovolaemic shock. She responded to initial fluid resuscitation.She was transferred to an acute general surgery hospital. On admission she was noted to have marked pallor, severe hypovolaemic shock (class III) and a tense distended abdomen. The general surgery and anaesthetic team were paged as an emergency within five minutes of the patient arriving. She had superficial abdominal bruising at the site of liposuction and mild diffuse abdominal tenderness. There was no abdominal guarding or signs of peritonism present. The bowel sounds were reduced and digital rectal examination was normal. Her blood results revealed haemoglobin level of 3.6 g/dL. She made a moderate recovery to aggressive fluid resuscitation. She was urgently transfused six units of whole blood, type specific blood was given within 15 minutes, followed by cross-matched blood within one hour. After initial resuscitation her blood pressure was stable at 110/60. Her repeat haemoglobin level was 10.6 g/dL. She continued to have persistent tachycardia, with a pulse rate of 110 bpm.A rapid Focused Abdominal Sonography for Trauma (FAST) abdominal ultrasound scan was performed within 30 minutes, first by the emergency department consultant, then by the radiology specialist registrar. The FAST scan was positive for intra-abdominal fluid; the source of bleeding could not be identified, however, as the scan was difficult to interpret due to the recent liposuction. A computed tomography (CT) scan was done within a hour of the ultrasound scan. It showed a large volume of free intraperitoneal fluid in perihepatic space, paracolic gutters and pelvis. The spleen was displaced medially with heterogeneous haematoma seen laterally with active contrast extravasation indicating persistent bleeding. The haemorrhage was extraperitoneal but deep to the abdominal wall musculature (Figure 1).As the patient had continuing abdominal distension and pain she underwent an emergency laparotomy within 4 hours of arriving in the resuscitation room. Perioperatively, she received six units of packed red cells, three units of fresh frozen plasma, one un...
Sclerosing encapsulating peritonitis (SEP) is a rare complication of chronic peritoneal dialysis and beta-blocker (practolol) usage. The authors report a case of idiopathic SEP developing in a 39-year-old woman with associated ovarian cysts and kerato-conjunctivitis sicca syndrome. These associations have not been reported previously. The histological diagnosis of SEP was made after laparotomy for intestinal obstruction. The patient continues to have chronic intestinal failure, managed conservatively by long-term parenteral nutrition and steroids for more than 12 years.
Ann R Coll Surg Engl 2010; 92: 307-310 307The incidence of cholelithiasis in the UK is 11-22%; approximately 10% of cases are symptomatic.1 Each year, over 25 000 patients are admitted to English hospitals with acute gallbladder disease, and 15% undergo emergency cholecystectomy. 2 In our district general hospital, laparoscopic cholecystectomy is performed both electively for symptomatic gallstone disease, and also as an emergency procedure during an acute admission. Previous studies have reported 30-day re-admission rates of 2-5% following elective laparoscopic cholecystectomy, 3,4 and 6% following emergency laparoscopic cholecystectomy. 5 However, in our experience, patients can present with symptoms several weeks after laparoscopic cholecystectomy, and there is little data regarding re-admission rates after 30 days' postoperatively. In addition, there are very few studies comparing postoperative outcomes following emergency laparoscopic cholecystectomy in district general hospitals and larger teaching units.Our aim was to determine whether there is a difference in 90-day re-admission rates following either elective or emergency laparoscopic cholecystectomy, and to compare our outcomes at a UK district general hospital with larger teaching centres. Patients and MethodsThe study was conducted at a district general hospital within eastern England with a catchment population of 180,000. Twenty-five patients were re-admitted within 90 days of their operation, of whom only 14 had complications directly related to their surgery (overall re-admission rate 4.3%). There was no statistical difference in re-admission rate or cause of re-admission between elective and emergency procedures. However, the mean time to re-admission following elective procedures was significantly longer (36 days; P = 0.0003). CONCLUSIONS Re-admission rates at our district general hospital are comparable to those reported by larger teaching centres. Current 30-day re-admission data may significantly underestimate morbidity rates and socio-economic cost following elective laparoscopic cholecystectomy. GASTROINTESTINAL SURGERY
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