Greater than 50% of patients with esophageal carcinoma are found to be incurable at the time of diagnosis, leaving only palliative options. Self-expanding metal stents (SEMs) are effective for relieving symptoms and complications associated with esophageal carcinoma and improving quality of life. We undertook a retrospective analysis to evaluate the experience of palliative esophageal stenting for symptomatic malignant dysphagia in our institution over a period of 7 years. Between January 1999 and January 2006, 126 patients who received SEMs for malignant dysphagia were identified using an upper gastrointestinal specialist nurse clinician database. Data were obtained from patient case notes, endoscopy, histopathology, radiology, and external agency databases. Of the 126 identified, 36 patients were excluded from the analysis. A number of variables including age, sex, presenting complaints, type of stent, indications of stenting, success or failure of stent insertion, survival rate, and complication rate were analyzed. Of the 90 patients, 55 (61%) were male and 35 (39%) were female. The mean age of patients was 70.79 (range 40-97) years. The predominant presenting complaints were dysphagia (n = 81) and weight loss (n = 48). The indication for stenting was worsening dysphagia in all patients. Tumors were confined to the distal esophagus and esophagogastric junction in 73 patients (81%), and the mid-esophagus in 17 (19%). Adenocarcinoma was identified in 61 patients (67.8%) and squamous cell carcinoma in 29 (32.2%). Stenting numbers were comparable in endoscopic and radiologic groups (47 vs. 43), with successful stent deployment in 89 patients. The 7- and 30-day mortality was 9% (n = 8) and 28% (n = 25), respectively. Comparable numbers of early deaths were seen in both radiologic (n = 13) and endoscopic (n = 12) groups. Causes of early inpatient death included hemorrhage (n = 5), pneumonia (n = 7), exhaustion (n = 2), cardiac causes (n = 3), perforation (n = 1), and sepsis (n = 1). The number of patients with complications was 41 (45.6%), 25 in the surgical group and 15 in the radiologic group; the difference was not significant (P = 0.13). The mean survival time was 92.5 (0-638) days and median survival time was 61 days. A subgroup of patients with complete dysphagia (score 4) gained a mean survival of 59 days. Those patients receiving adjuvant chemotherapy or radiotherapy survived significantly longer than those receiving stenting alone (152.8 days vs. 71.8 days). There is no significant difference in complications or survival when using endoscopic or radiologic methods to deploy SEMs in patients with inoperable esophageal cancer. Mortality is low; however, the morbidity rate is significant. Patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.

Background Elective surgery in obese adults carries a higher risk of post‐operative infection and prolonged hospital stays, and surgeons may postpone surgery for patients with obesity until they lose weight. The present study aimed to determine the efficacy of a dietitian‐led very low calorie diet (VLCD)‐based model of care with respect to achieving weight loss for obese patients prior to surgery. Methods This mixed‐methods study included a medical chart audit of patients referred to a VLCD‐based model over 23 months, as well as a survey of recently treated patients and surgeons who utilised the model. Preoperative weight loss targets were set by surgeons, and the dietitian prescribed individualised VLCD‐based treatment. Efficacy was determined as weight loss considered sufficient for surgery, clinical safety of VLCD‐based treatment, feasibility, and stakeholder value. Pre/post‐intervention differences in clinical measures were explored by paired t‐test or Wilcoxon tests as appropriate. Results Data on seventy‐eight eligible patients [mean (SD) 45 (13) years, 90% female, body mass index 44.3 (6.2) kg m–2] demonstrated significant mean (SD) weight loss of 7.4% (5.3%) body weight (P < 0.05). Most patients (70%, n = 50/71) achieved sufficient weight loss to proceed to surgery. Fifty‐six per cent of patients reported mild side effects (n = 43/77) and none led to treatment cessation. Surgeons reported VLCD‐based treatment made operations easier (83%, n = 10/12) and shorter (75%, n = 9/12) and all recommended the model of care. All surveyed patients (n = 24) reported satisfaction with their VLCD‐based model experience. Conclusions A dietitian‐led VLCD‐based model achieved sufficient weight loss to facilitate elective surgery for most patients. The approach was feasible, highly valued by patients and surgeons, and resulted in perceived surgical benefits.

This meta-analysis demonstrates a significant decrease in complications in patients with severe GSP managed with early ERCP/ES compared with conservative management. As far as the mortality is concerned, no significant decrease was observed in mortality even in severe GSP patients treated with early ERCP/ES.

Background Population studies have confirmed an increase in the proportion of elderly patients (≥65 years of age), and this could be expected to be reflected in trauma admissions and outcomes. This study aims to investigate the demographic trends for elderly patients admitted following trauma to Auckland City Hospital (ACH) and their outcomes. Materials and methods The ACH Trauma Database was searched from 1995 to 2014, and data including date of admission, injury cause, age, sex, mortality, Injury Severity Score (ISS), Intensive Care Unit (ICU) stay and length of stay (LOS) were extracted. Results A total of 26,882 patients were identified, with 4428 patients ≥65 years of age admitted following trauma. In the mid‐1990s between 200 and 250 trauma patients ≥65 years were admitted to ACH annually. This has increased to >400 in 2014 and now represents >20% of all admissions. Females are over represented (61.7%) in those ≥65 years (vs. 29.4% in < 65 years, p < 0.001), and falls are the greatest cause of admission for trauma in those ≥65 years at 72% (vs. 36.9% in those < 65 years, p < 0.001). Elderly trauma patients are more than twice as likely to die (5.6% vs. 2.3%, p < 0.001) compared with trauma patients < 65 years despite an identical median ISS of 4 (p = 0.86). Furthermore, of those ≥65 years, 2.2% died of minor/moderate trauma (ISS ≤ 15) versus only 0.12% for those < 65 years confirming the complexities of ageing physiology in a trauma setting. Until 2003, mortality from trauma in elderly patients closely paralleled the rate of severe trauma admissions (ISS ≥ 16), but after 2003, despite a steady increase in severe trauma in this cohort, mortality rates have fallen. Conclusions Elderly patients bring with them a greater burden of co‐morbidities, and trauma admission of elderly patients has almost doubled over 20 years, including severe trauma (ISS ≥ 16), but despite this mortality has decreased. Integration of services into the new ACH in 2003 as well as improving trauma and medical care may be possible explanations. Further resources will be required to meet service demand, along with consideration of strategies to integrate multi‐disciplinary care and consolidate trauma management for this vulnerable patient group.