Abstract Background and aims There has been no comprehensive evaluation of the efficacy of transcutaneous electric nerve stimulation (TENS) for acute low back pain (LBP). The aim of this systematic review was to investigate the efficacy and safety of TENS for acute LBP. Methods We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL and PsycINFO (inception to May 2018) for randomised placebo controlled trials. The primary outcome measure was pain relief in the immediate term (within 2-weeks of administration) assessed using the 100 mm visual analogue scale. A mean difference of at least 10 points on the 100-point pain scale was considered clinically significant. Methodological quality of the eligible studies was assessed using the PEDro scale and overall quality assessment rating was assessed using GRADE. Results Three placebo controlled studies (n = 192) were included. One low quality trial (n = 63) provides low quality evidence that ~30 min treatment with TENS in an emergency-care setting provides clinically worthwhile pain relief for moderate to severe acute LBP in the immediate term compared with sham TENS [Mean Difference (MD) – 28.0 (95% CI – 32.7, −23.3)]. Two other studies which administered a course of TENS over 4–5 weeks, in more usual settings provide inconclusive evidence; MD −2.75 (95% CI −11.63, 6.13). There was limited data on adverse events or long term follow-up. Conclusions The current evidence is insufficient to support or dismiss the use of TENS for acute LBP. Implications There is insufficient evidence to guide the use of TENS for acute LBP. There is low quality evidence of moderate improvements in pain with a short course of TENS (~30 min) during emergency transport of patients to the hospital. Future research should evaluate whether TENS has an opioid sparing role in the management of acute LBP.

Introduction Endoscopic retrograde cholangio‐pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient‐based training in ERCP however models to date have been unconvincing. Methods This ERCP simulation model was constructed from moulded meshed silicone by co‐designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists. Results From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009). Conclusions The simulator showed statistically significant results in face, content, and construct validity. A follow‐up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.

The corresponding author is not a recipient of a research scholarship.

Paraoesophageal hernias (PEH) are often symptomatic and can lead to life-threatening complications such as volvulus and ischemia. Recently dyspnoea was reported as most prevalent symptom of giant hiatus herniae. The aim of this study is to evaluate the effect of surgery on resolution of dyspnoea amongst patients with giant hiatus hernia defined as greater than 30% of the stomach above the diaphragm. Data were extracted from a prospectively maintained single surgeon database containing records of patients undergoing composite hernia repair. Patients who underwent composite laparoscopic repair of giant paraoesophageal hernia between March 2009 and December 2015 and had documented dyspnoea were included. Inclusion criteria were met by 154 patients. Primary outcome of the analysis included preoperative and postoperative dyspnoea. Secondary outcomes included complications and post-operative symptoms. The mean age at time of surgery was 71.2 years (range 49–93, SD 9.66). Surgery resulted in near complete resolution of dyspnoea (2.6% postoperatively, P-value <0.001). Significant improvement was also noted in dysphagia, although not micro-aspiration. Dyspnoea resolves following laparoscopic repair of giant paraoesophageal hernia. The presence of dyspnoea should be regarded as an indication rather than a barrier to surgery. We recommend all patients with giant hiatus hernia to be assessed by a specialist surgical service.

Paraoesophageal hernias (PEH) are often symptomatic and can lead to life-threatening complications including volvulus and ischaemia. Dyspnoea was recently reported as the most prevalent symptom of giant PEHs, although it has been perceived by some as a contraindication to surgery. The aim of this study is to evaluate the effect of surgery on resolution of dyspnoea amongst patients with giant hiatus hernia defined as greater than 30% of the stomach above the diaphragm. Data were extracted from a prospectively maintained single-surgeon database containing records of patients undergoing composite hernia repair. Patients who underwent standardised composite laparoscopic repair of giant PEH without mesh prosthesis between March 2009 and December 2015 and had documented dyspnoea were included. Patients were reviewed post-operatively at 6 weeks, 3 months, 12 months, and then annually unless more frequent visits were clinically indicated. The primary outcome of the analysis was the difference in patient-reported pre-operative and post-operative dyspnoea. Secondary outcomes included differences in pre-operative and post-operative dysphagia and clinical aspiration as well as recurrence of PEH of any size. Inclusion criteria were met by 154 patients. There were 127 females (82.5%) and 27 males (17.5%). The average age at time of operation was 71.2 years (range 49–93, SD 9.66). The average hernia size was 64%, based on intraoperative evaluation by the surgeon (range 30–100%, SD 20.2). After surgery, there was a significant improvement in all symptoms: dyspnoea (100% pre-operatively, 2.6% post-operatively, P¬ < 0.001), dysphagia (46.1% pre-operatively, 15.6% post-operatively, P < 0.001) and clinical aspiration (9.1% pre-operatively, 1.3% post-operatively, P = 0.002). Hernia recurrence was found in 37 patients (24.0%) amongst whom dyspnoea was rare (5.4%, 2 patients). This study suggests that dyspnoea resolves following laparoscopic repair of giant paraoesophageal hernia. This may be explained by the effect of surgical repair on improving hernia-related atrial compression, pulmonary congestion and reduced lung capacities. The presence of dyspnoea should be regarded as an indication rather than a barrier to surgery. Therefore, we recommend all patients with giant hiatus hernia to be assessed by a specialist surgical service.