Annals of The Royal College of Surgeons of England, Mar 1, 2017
INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to... more INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to mixed outcomes. In the presence of preoperative dysphagia and oesophageal dysmotility, this procedure has engendered concern in certain regards. METHODS This paper describes a consecutive series of laryngopharyngeal reflux (LPR) patients with a high frequency of dysmotility. Patients were selected for surgery with 24-hour dual channel pH monitoring, oesophageal manometry and standardised reflux scintigraphy. RESULTS Following careful patient selection, 33 patients underwent fundoplication by laparoscopy. Surgery had high efficacy in symptom control and there was no adverse dysphagia. CONCLUSIONS Evidence of proximal reflux can select a group of patients for good results of fundoplication for atypical symptoms.
The Annals of The Royal College of Surgeons of England
Introduction Dyspnoea is common in patients with giant paraoesophageal hernia (PEH). Pulmonary as... more Introduction Dyspnoea is common in patients with giant paraoesophageal hernia (PEH). Pulmonary aspiration has not previously been recognised as a significant contributory factor. Aspiration pneumonia in association with both gastro-oesophageal reflux disease (GORD) and PEH has a high mortality rate. There is debate about routine anti-reflux measures with surgical repair. Reflux aspiration has been examined in a consecutive cohort using scintigraphic scanning and symptoms. Methods Reflux aspiration scintigraphy (RASP) results and symptoms were evaluated in consecutive patients with PEH managed in our service between January 2012 and March 2017. Results PEH was diagnosed in 96 patients. Preoperative reflux pulmonary scanning was performed in 70 patients: 54 were female (77.1%) and the mean age was 68 years (range 49–85). Dyspnoea was the most common symptom (77.1%), and a symptomatic history of aspiration was seen in 18 patients (25.7%). Clinical aspiration was confirmed by RASP in 13...
Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations.... more Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h. 187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023). Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.
No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intralumin... more No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. 105 patients with LPR [31 males (29.5%), median age 60 years (range 20–87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002). Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.
BACKGROUND Neoadjuvant chemotherapy (NACT) and oesophagectomy is the standard of care for resecta... more BACKGROUND Neoadjuvant chemotherapy (NACT) and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas. Survival outcomes following resection have been improving over time while NACT remain largely unchanged. Indeed, a recent meta-analysis of randomized control trials did not demonstrate a survival benefit in adding NACT, raising the possibility that improved surgical techniques may be reducing the perceived effectiveness of NACT. AIM To compare the effect of addition of NACT to a standardized surgery and lymphadenectomy on overall and disease-free survival in patients undergoing curative oesophagectomy for oesophageal adenocarcinoma. METHODS Patient data were analysed from a prospectively maintained surgical survival database. Demographic, surgical, and survival outcomes were compared between groups according to treatment and nodal count. RESULTS The data of 243 consecutive patients were identified. 79 patients were given NACT and 162 had surgery only. The NACT group were younger, and there was less frequent stage I adenocarcinoma. Overall survival was similar between NACT and surgery only groups (5YS: 48.7% vs 42.5%; P = 0.113), as was disease-free survival (5YS: 40.6% vs 39.9%; P = 0.635). There were ≥ 30 nodes removed in 46 patients, and < 30 in 197 patients, but were otherwise similar. There was improved survival in patients with ≥ 30 nodes removed than those with < 30 nodes (5YS: 64.4% vs 40.7%; P = 0.015), and a better disease-free survival that neared significance (5YS: 54.9% vs 36.6%; P = 0.078). CONCLUSION NACT did not appear to affect overall or disease-free survival. However, an overall survival benefit was observed in patients with ≥ 30 lymph nodes removed, and a benefit in disease-free survival which was not significant.
Oesophagectomy is the mainstay in the curative management of oesophageal cancer. Curative surge... more Oesophagectomy is the mainstay in the curative management of oesophageal cancer. Curative surgery is associated with considerable morbidity and potential mortality. Surgeons are increasingly treating older patients presenting with oesophageal cancer as the population ages. This study aimed to assess the effect of age on short term surgical outcomes, mortality, as well as overall and disease-free survival, in patients undergoing curative oesophagectomy for cancer. Methods Patient data were analysed from a prospectively maintained database. Demographic, surgical, and survival outcomes were compared between groups according to age less than 75 years or 75 and older. Results Oesophagectomy was performed in 351 patients between 1990 and 2019 (283 patients <75 years, 68 patients ≥75 years). There was a higher rate of neoadjuvant chemotherapy in the <75 year old group than the ≥75 group (37.7% vs. 7.4%; p < 0.001); the two groups were otherwise similar. The 30-day mortality betw...
Background Symptom recurrence after primary hiatus hernia surgery is an established problem and r... more Background Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to assess the relationship between primary symptom indication and a variety of objective and subjective post operative outcomes. Methods A prospectively maintained single surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. This was a consecutive cohort of adults greater than 18 years of age. The symptomatic, anatomical, and physiological indications for surgery were reviewed. The symptoms described by patients were grouped into four categories: typical reflux, volume, obstructive and gastric motility symptoms. The intraoperative findings and post operative outcomes were analysed. The dataset consisted of 379 patients, of whom 59% were female. Th...
Purpose Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate rega... more Purpose Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years. Methods Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis. Results 862 giant PEH repairs met selection criter...
Background: Hiatal hernia is a common finding on endoscopy; clinical management and prognosis dif... more Background: Hiatal hernia is a common finding on endoscopy; clinical management and prognosis differ significantly depending on its type. Symptomatic paraoesophageal hiatus hernia (PEH) (type II-IV) usually require surgery whereas sliding hiatal hernia (type I) associated with reflux disease can be frequently medically managed. We examined the accuracy of gastroscopy and barium contrast meal [upper gastrointestinal (GI) study] in the diagnosis of PEH and gastric volvulus (GV). Methods: The reports of gastroscopy and barium meal in patients who underwent laparoscopic fundoplication were compared with intraoperative finding of PEH in a retrospective cohort of consecutive patients with PEH treated between January 1st 2008 to 2017. Results: PEH was diagnosed in 231 consecutive patients; 130 patients were eligible for the study. Endoscopy and barium meal reports were both available in 60 patients, endoscopy in 24 and barium meal in 46 patients. Sensitivity of endoscopy and barium study in diagnosing the presence of hiatal hernia were 97.61% and 100% respectively. Despite this, both endoscopy and barium study were unreliable for type of hiatal hernia with sensitivity of 8.33% and 38.68% respectively. The sensitivity of endoscopy and barium study in diagnosing chronic GV (CGV) were 10.7% and 20.5% respectively. Conclusions: The anatomical description lacked consistency with both endoscopy and radiology reporting; standardisation of reporting may increase the reliability of these tests. Identification of the type of hiatus hernia (HH) is important to accurately risk stratify the disease together with patient symptoms. Both barium meal and endoscopy had poor sensitivity in detecting the type of HH but highly sensitive for diagnosing the presence of HH.
American journal of nuclear medicine and molecular imaging, 2020
Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries.... more Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries. It may present with the typical symptoms of heartburn and regurgitation or with the effects of extra-esophageal disease. We have developed and validated a scintigraphic test that evaluates reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration. We hypothesized that the test may be able to separate physiologic reflux from pathological reflux and examined this possibility in normal asymptomatic volunteers. Asymptomatic volunteers were screened with the Belafsky reflux symptom index (RSI) and entered into the trial if scores were less than 13. 99mTc Phytate was ingested orally and dynamic studies from the pharynx to the stomach were obtained while upright and supine. A delayed study of the thorax was also obtained for lung aspiration of refluxate. Studies were semi-quantitated graphically as time-activity curves. A total of 25 volunteers were studied ...
Comment on: Progression of hiatal hernias [1] Thank you for this very excellent communication. Th... more Comment on: Progression of hiatal hernias [1] Thank you for this very excellent communication. Those of us who work extensively in this area have long recognised the phenomenon of the historically enlarging hiatus hernia, with little documented supporting evidence. It is nice some are now available. Many patients describe having a small hiatus hernia with typical reflux symptoms of heartburn and regurgitation which over many decades goes on to become entrapment symptoms (dysphagia, early satiety, post-prandial chest discomfort) as the hernia has become larger, often seen on serial barium meal over years. It has been evident during surgical management of these patients that the diaphragmatic defect is most commonly anterior, the pericardium being visualised behind the larger anterior crural defect as soon as the sack is reduced. This is not the situation with the smaller hernia where the pericardium is not exposed on dissecting the hiatus. This has led me to develop the concept of fa...
Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pu... more Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. Methods: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. Results: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst ...
Objectives: Fungal pneumonia in the immune competent host is a rarity with few reported cases in ... more Objectives: Fungal pneumonia in the immune competent host is a rarity with few reported cases in the literature. We present a series of 7 cases of recurrent fungal pneumonia in association with allergic fungal rhinosinusitis and gastroesophageal reflux disease (GERD). We hypothesised that recurrent infection may have been transported from the infected paranasal sinuses into the lung by GERD as the process was terminated by surgical fundoplication in 2 of these patients. Methods: Patients were recruited into the study if they were immune competent and had recurrent fungal pneumonia and GERD. Allergic fungal rhinosinusitis was proven by biopsy. GERD was investigated by a scintigraphic test that assessed local oesophageal disease, lung aspiration and head and neck involvement with a hybrid gamma camera and X-ray computed tomography. Results: All patients were shown to have GERD with 5/7 showing paranasal sinus contamination and 7/7 showing laryngopharyngeal involvement and 6/7 lung aspiration. One patient had characteristics strongly predictive of aspiration. Fundoplication led to cessation of fungal lung infection in two patients. Conclusion: Recurrent fungal pneumonia in the immune competent host should raise the possibility of re-infection from the paranasal sinuses, especially in patients with GERD.
Giant hiatus hernia (GHH) is usually symptomatic and can have significant impact on a patient’s... more Giant hiatus hernia (GHH) is usually symptomatic and can have significant impact on a patient’s quality of life. There is ongoing debate about optimal technique of giant hiatus hernia repair. This paper aims to look at the outcomes of laparoscopic composite repair of giant hiatus hernia from a large single centre cohort. Methods A retrospective analysis of prospectively maintained database was performed. Patients undergoing composite repair for GHH defined as >30% stomach above diaphragm were included. Primary outcome was hernia recurrence. Secondary outcomes were perioperative morbidity and mortality, correlation of symptoms and hernia recurrence post operatively, need for revision surgery, resolution of symptoms post operatively and patient self-reported quality of life (GIQOL, Visik score). Results Inclusion criteria were met by 221 patients. Post-operative endoscopic and/or barium swallow follow up was performed in 198 patients with 23.74% recurrence rate. There was no corr...
The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (... more The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD. Methods: A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies. Results: The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. Lower oesophageal spincter tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration. Conclusion: Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.
Annals of The Royal College of Surgeons of England, Mar 1, 2017
INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to... more INTRODUCTION Fundoplication for laryngopharyngeal disease with oesophageal dysmotility has led to mixed outcomes. In the presence of preoperative dysphagia and oesophageal dysmotility, this procedure has engendered concern in certain regards. METHODS This paper describes a consecutive series of laryngopharyngeal reflux (LPR) patients with a high frequency of dysmotility. Patients were selected for surgery with 24-hour dual channel pH monitoring, oesophageal manometry and standardised reflux scintigraphy. RESULTS Following careful patient selection, 33 patients underwent fundoplication by laparoscopy. Surgery had high efficacy in symptom control and there was no adverse dysphagia. CONCLUSIONS Evidence of proximal reflux can select a group of patients for good results of fundoplication for atypical symptoms.
The Annals of The Royal College of Surgeons of England
Introduction Dyspnoea is common in patients with giant paraoesophageal hernia (PEH). Pulmonary as... more Introduction Dyspnoea is common in patients with giant paraoesophageal hernia (PEH). Pulmonary aspiration has not previously been recognised as a significant contributory factor. Aspiration pneumonia in association with both gastro-oesophageal reflux disease (GORD) and PEH has a high mortality rate. There is debate about routine anti-reflux measures with surgical repair. Reflux aspiration has been examined in a consecutive cohort using scintigraphic scanning and symptoms. Methods Reflux aspiration scintigraphy (RASP) results and symptoms were evaluated in consecutive patients with PEH managed in our service between January 2012 and March 2017. Results PEH was diagnosed in 96 patients. Preoperative reflux pulmonary scanning was performed in 70 patients: 54 were female (77.1%) and the mean age was 68 years (range 49–85). Dyspnoea was the most common symptom (77.1%), and a symptomatic history of aspiration was seen in 18 patients (25.7%). Clinical aspiration was confirmed by RASP in 13...
Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations.... more Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h. 187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023). Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.
No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intralumin... more No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. 105 patients with LPR [31 males (29.5%), median age 60 years (range 20–87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002). Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.
BACKGROUND Neoadjuvant chemotherapy (NACT) and oesophagectomy is the standard of care for resecta... more BACKGROUND Neoadjuvant chemotherapy (NACT) and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas. Survival outcomes following resection have been improving over time while NACT remain largely unchanged. Indeed, a recent meta-analysis of randomized control trials did not demonstrate a survival benefit in adding NACT, raising the possibility that improved surgical techniques may be reducing the perceived effectiveness of NACT. AIM To compare the effect of addition of NACT to a standardized surgery and lymphadenectomy on overall and disease-free survival in patients undergoing curative oesophagectomy for oesophageal adenocarcinoma. METHODS Patient data were analysed from a prospectively maintained surgical survival database. Demographic, surgical, and survival outcomes were compared between groups according to treatment and nodal count. RESULTS The data of 243 consecutive patients were identified. 79 patients were given NACT and 162 had surgery only. The NACT group were younger, and there was less frequent stage I adenocarcinoma. Overall survival was similar between NACT and surgery only groups (5YS: 48.7% vs 42.5%; P = 0.113), as was disease-free survival (5YS: 40.6% vs 39.9%; P = 0.635). There were ≥ 30 nodes removed in 46 patients, and < 30 in 197 patients, but were otherwise similar. There was improved survival in patients with ≥ 30 nodes removed than those with < 30 nodes (5YS: 64.4% vs 40.7%; P = 0.015), and a better disease-free survival that neared significance (5YS: 54.9% vs 36.6%; P = 0.078). CONCLUSION NACT did not appear to affect overall or disease-free survival. However, an overall survival benefit was observed in patients with ≥ 30 lymph nodes removed, and a benefit in disease-free survival which was not significant.
Oesophagectomy is the mainstay in the curative management of oesophageal cancer. Curative surge... more Oesophagectomy is the mainstay in the curative management of oesophageal cancer. Curative surgery is associated with considerable morbidity and potential mortality. Surgeons are increasingly treating older patients presenting with oesophageal cancer as the population ages. This study aimed to assess the effect of age on short term surgical outcomes, mortality, as well as overall and disease-free survival, in patients undergoing curative oesophagectomy for cancer. Methods Patient data were analysed from a prospectively maintained database. Demographic, surgical, and survival outcomes were compared between groups according to age less than 75 years or 75 and older. Results Oesophagectomy was performed in 351 patients between 1990 and 2019 (283 patients <75 years, 68 patients ≥75 years). There was a higher rate of neoadjuvant chemotherapy in the <75 year old group than the ≥75 group (37.7% vs. 7.4%; p < 0.001); the two groups were otherwise similar. The 30-day mortality betw...
Background Symptom recurrence after primary hiatus hernia surgery is an established problem and r... more Background Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to assess the relationship between primary symptom indication and a variety of objective and subjective post operative outcomes. Methods A prospectively maintained single surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. This was a consecutive cohort of adults greater than 18 years of age. The symptomatic, anatomical, and physiological indications for surgery were reviewed. The symptoms described by patients were grouped into four categories: typical reflux, volume, obstructive and gastric motility symptoms. The intraoperative findings and post operative outcomes were analysed. The dataset consisted of 379 patients, of whom 59% were female. Th...
Purpose Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate rega... more Purpose Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years. Methods Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis. Results 862 giant PEH repairs met selection criter...
Background: Hiatal hernia is a common finding on endoscopy; clinical management and prognosis dif... more Background: Hiatal hernia is a common finding on endoscopy; clinical management and prognosis differ significantly depending on its type. Symptomatic paraoesophageal hiatus hernia (PEH) (type II-IV) usually require surgery whereas sliding hiatal hernia (type I) associated with reflux disease can be frequently medically managed. We examined the accuracy of gastroscopy and barium contrast meal [upper gastrointestinal (GI) study] in the diagnosis of PEH and gastric volvulus (GV). Methods: The reports of gastroscopy and barium meal in patients who underwent laparoscopic fundoplication were compared with intraoperative finding of PEH in a retrospective cohort of consecutive patients with PEH treated between January 1st 2008 to 2017. Results: PEH was diagnosed in 231 consecutive patients; 130 patients were eligible for the study. Endoscopy and barium meal reports were both available in 60 patients, endoscopy in 24 and barium meal in 46 patients. Sensitivity of endoscopy and barium study in diagnosing the presence of hiatal hernia were 97.61% and 100% respectively. Despite this, both endoscopy and barium study were unreliable for type of hiatal hernia with sensitivity of 8.33% and 38.68% respectively. The sensitivity of endoscopy and barium study in diagnosing chronic GV (CGV) were 10.7% and 20.5% respectively. Conclusions: The anatomical description lacked consistency with both endoscopy and radiology reporting; standardisation of reporting may increase the reliability of these tests. Identification of the type of hiatus hernia (HH) is important to accurately risk stratify the disease together with patient symptoms. Both barium meal and endoscopy had poor sensitivity in detecting the type of HH but highly sensitive for diagnosing the presence of HH.
American journal of nuclear medicine and molecular imaging, 2020
Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries.... more Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries. It may present with the typical symptoms of heartburn and regurgitation or with the effects of extra-esophageal disease. We have developed and validated a scintigraphic test that evaluates reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration. We hypothesized that the test may be able to separate physiologic reflux from pathological reflux and examined this possibility in normal asymptomatic volunteers. Asymptomatic volunteers were screened with the Belafsky reflux symptom index (RSI) and entered into the trial if scores were less than 13. 99mTc Phytate was ingested orally and dynamic studies from the pharynx to the stomach were obtained while upright and supine. A delayed study of the thorax was also obtained for lung aspiration of refluxate. Studies were semi-quantitated graphically as time-activity curves. A total of 25 volunteers were studied ...
Comment on: Progression of hiatal hernias [1] Thank you for this very excellent communication. Th... more Comment on: Progression of hiatal hernias [1] Thank you for this very excellent communication. Those of us who work extensively in this area have long recognised the phenomenon of the historically enlarging hiatus hernia, with little documented supporting evidence. It is nice some are now available. Many patients describe having a small hiatus hernia with typical reflux symptoms of heartburn and regurgitation which over many decades goes on to become entrapment symptoms (dysphagia, early satiety, post-prandial chest discomfort) as the hernia has become larger, often seen on serial barium meal over years. It has been evident during surgical management of these patients that the diaphragmatic defect is most commonly anterior, the pericardium being visualised behind the larger anterior crural defect as soon as the sack is reduced. This is not the situation with the smaller hernia where the pericardium is not exposed on dissecting the hiatus. This has led me to develop the concept of fa...
Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pu... more Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. Methods: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. Results: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst ...
Objectives: Fungal pneumonia in the immune competent host is a rarity with few reported cases in ... more Objectives: Fungal pneumonia in the immune competent host is a rarity with few reported cases in the literature. We present a series of 7 cases of recurrent fungal pneumonia in association with allergic fungal rhinosinusitis and gastroesophageal reflux disease (GERD). We hypothesised that recurrent infection may have been transported from the infected paranasal sinuses into the lung by GERD as the process was terminated by surgical fundoplication in 2 of these patients. Methods: Patients were recruited into the study if they were immune competent and had recurrent fungal pneumonia and GERD. Allergic fungal rhinosinusitis was proven by biopsy. GERD was investigated by a scintigraphic test that assessed local oesophageal disease, lung aspiration and head and neck involvement with a hybrid gamma camera and X-ray computed tomography. Results: All patients were shown to have GERD with 5/7 showing paranasal sinus contamination and 7/7 showing laryngopharyngeal involvement and 6/7 lung aspiration. One patient had characteristics strongly predictive of aspiration. Fundoplication led to cessation of fungal lung infection in two patients. Conclusion: Recurrent fungal pneumonia in the immune competent host should raise the possibility of re-infection from the paranasal sinuses, especially in patients with GERD.
Giant hiatus hernia (GHH) is usually symptomatic and can have significant impact on a patient’s... more Giant hiatus hernia (GHH) is usually symptomatic and can have significant impact on a patient’s quality of life. There is ongoing debate about optimal technique of giant hiatus hernia repair. This paper aims to look at the outcomes of laparoscopic composite repair of giant hiatus hernia from a large single centre cohort. Methods A retrospective analysis of prospectively maintained database was performed. Patients undergoing composite repair for GHH defined as >30% stomach above diaphragm were included. Primary outcome was hernia recurrence. Secondary outcomes were perioperative morbidity and mortality, correlation of symptoms and hernia recurrence post operatively, need for revision surgery, resolution of symptoms post operatively and patient self-reported quality of life (GIQOL, Visik score). Results Inclusion criteria were met by 221 patients. Post-operative endoscopic and/or barium swallow follow up was performed in 198 patients with 23.74% recurrence rate. There was no corr...
The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (... more The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD. Methods: A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies. Results: The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. Lower oesophageal spincter tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration. Conclusion: Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.
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Papers by Gregory Falk