Surgical Assessment Units: The Key to More Efficient Emergency Surgical Provision and Admissions?

BACKGROUND: Hospitals establish surgical assessment units to promote efficiency and improve patient experience. Surgical assessment units are believed to reduce unnecessary admissions. We evaluated a hospital's on-call surgery service without this facility to determine benefits of implementation. METHODS: All emergency surgery referrals made over a 3-month period were recorded, including whether the patient was immediately discharged directly from emergency surgery. Data collection was undertaken by each surgical firm on-call. Immediate discharges were classed as patients not admitted to the hospital overnight (regardless of whether the patient had outpatient follow-up planned). RESULTS: Nine hundred eighty-four referrals were identified. Seven hundred ninety-three referrals had complete data and therefore were included for analysis. Of these, 349 patients (44.0% of referrals) were immediately discharged from emergency surgery, thereby preventing unnecessary admissions (a high proportion of surgical referrals not requiring hospital admission). This improves hospital efficiency, cost savings, and patient experience. Immediate discharge was less frequent and more difficult to accomplish if patients were initially assessed on wards (instead of in the emergency department). This is likely due to patients' perceptions that admission was required when transferred from emergency department to a ward. CONCLUSIONS: Establishment of surgical assessment units has multiple potential benefits to patients, hospitals and clinicians. Appropriateness of surgical assessment unit implementation by every hospital ought to be evaluated.

Adult intussusception associated with mesenteric Meckel's diverticulum and antimesenteric ileal polyp.

Meckel's diverticulum is the most common congenital abnormality affecting the gastrointestinal tract, affecting 4% of the general population. It is classically located on the antimesenteric border of the ileum within 100 cm of the ileocaecal valve. Complications may include haemorrhage, bowel obstruction, diverticulitis, perforation and malignancy. This report explores the case of intussusception in an adult, in association with a mesenteric Meckel's diverticulum and adjacent benign polyp. A 40-year-old man presented with acute abdominal pain, affecting the central abdomen and both flanks. CT imaging revealed small bowel intussusception, with either a Meckel's diverticulum or polyp acting as a lead point. Intraoperatively, the intussusception had already resolved; however, an inflamed outpouching was identified on the mesenteric border of the ileum, with a firm mass palpable within the bowel lumen. A 70 mm small bowel resection and primary anastomosis were performed. Histopathological analysis confirmed an inflamed Meckel's diverticulum as well as an adjacent diverticulum comprising a benign polyp.

Reno-duodenal fistula as a complication of longstanding renal tract calculus.

We present a rare case detailing the investigations and subsequent treatment of a lady who presented with a reno-duodenal fistula and perinephric abscess as a complication of staghorn calculus and recurrent upper urinary tract infections. Treatment involved antibiotics, nephrostomy, endoscopic closure of the fistula tract with clips, radiological drain insertion and, ultimately, nephrectomy with primary omental patch closure of the duodenal defect. We discuss the incidence of fistula tract formation as a complication of staghorn calculi, as well as investigations and management strategies employed in the literature to treat such complications, which span from conservative treatment to nephrectomy and closure of the intestinal defect. We illustrate the post-operative complications such patients are prone to and discuss these in context of the case. Whilst such cases are rare clinicians should be vigilant for complications associated with chronic inflammatory processes occurring in the urinary tract and investigate accordingly.

Gossypiboma: a ghastly find.

A gossypiboma is a mass within a patient's body comprising a cotton matrix surrounded by a foreign body granuloma. We describe an unusual presentation of a gossypiboma presenting in a 32-year-old man with acute epigastric pain and haematemesis. His surgical history revealed an emergency laparotomy following a road traffic accident 16 years ago. Initial gastroscopy showed extrinsic stomach compression. An abdominal ultrasound scan followed by a CT scan evidenced a large, well-defined, predominantly cystic mass with some solid areas occupying the left hypochondrium. Conservative management with insertion of a percutaneous drain proved to be inefficient. A laparotomy was performed; intraoperatively, the cyst was found to be ruptured and within it, a large surgical gauze was found. This was removed but required a distal pancreatectomy and gastrectomy for complete excision. He was discharged on day 74 of admission with outpatient follow-up.

'Wormy'form appendix.

Appendicitis and helminth infections are both common conditions in children. However, helminths (pinworms) infestation causing appendiceal luminal obstruction and presenting as appendicitis is uncommon.

Multivariate analysis of clinicopathological factors influencing survival following esophagectomy for cancer.

BACKGROUND: A number of clinicopathological characteristics can influence survival following esophagectomy for cancer. The aim of this study was to determine the factors affecting survival in a consecutive series of patients undergoing esophagectomy for cancer at a single tertiary centre over a 7 year period. MATERIALS & METHODS: We analyzed a prospective database of 314 consecutive patients (247 males and 67 females), with a mean age of 62.8 +/- 9.1 years, who underwent esophagectomy for cancer at a single, high-volume centre between January 2000 and June 2007. The impact of 11 variables on survival following esophagectomy was determined by univariate and multivariate analysis. RESULTS: On univariate analysis, gender, ASA grade, blood transfusion, type of cancer, tumor stage, lymph node status, lymphovascular invasion (LVI), longitudinal resection margin (LRM) involvement and circumferential resection margin (CRM) involvement were significant (p<0.05) negative factors for survival. Multivariate analysis using Cox proportional hazard regression demonstrated that the only independent factors negatively impacting on survival were ASA grade (p=0.012), tumor stage (p=0.009), LVI (p=0.009) and LRM involvement (p=0.031). CONCLUSIONS: In the current study we demonstrated that independent variables effecting survival after esophagectomy for cancer were ASA grade, tumor stage, lymphovascular invasion and longitudinal resection margin involvement. Contrary to other studies we did not find CRM involvement to be an independent predictor for survival.

A possible variant of Bouveret's syndrome presenting as a duodenal stump obstruction by a gallstone after Roux-en-Y gastrectomy: a case report.

INTRODUCTION: Bouveret's syndrome is characterized by gastric outlet obstruction due to a gallstone in the duodenum, usually in association with a cholecystoduodenal fistula. CASE PRESENTATION: We report the case of a 69-year-old Caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone Roux-en-Y gastrectomy. CONCLUSIONS: Duodenal stump obstruction after Roux-en-Y gastrectomy is rare, and may be difficult to manage. Patients who present with upper gastrointestinal or pancreatobiliary pathology after previous gastric surgery should be managed in centres with the availability of appropriate endoscopic and surgical experience.

Transhiatal oesophagectomy: treatment of choice for high-grade dysplasia.

OBJECTIVE: To demonstrate that transhiatal oesophagectomy should remain the gold standard treatment for patients with high-grade dysplasia. BACKGROUND: The conventional management of high-grade dysplasia of the oesophagus is surgery. Perceived high incidence of operative morbidity and mortality associated with oesophagectomy has led some to advocate alternative less invasive treatments such as endoscopic mucosal resection (EMR) and photodynamic therapy (PDT). We present our data on the use of transhiatal oesophagectomy for the management of high-grade dysplasia. METHODS: Twenty-three patients underwent transhiatal oesophagectomy for biopsy-proven high-grade dysplasia in a high volume centre, between March 2000 and December 2006. Twenty-two were male and 1 female with a mean age of 63.5 years (+/- 6.5). Staging was ascertained by gastroscopy, EUS and CT. Two patients had PET CT. ASA grade was I (2), II (14), III (6) and IV (1). RESULTS: Clinical anastomotic leak occurred in two patients (9%); this was managed conservatively. Four patients required intensive care admission. Occult adenocarcinoma was found in 35% (8/23) of surgical specimens; there were no involved nodes present. No re-operations were required. Median length of stay was 15 days (10-69). Thirty-day and in-hospital mortality was zero. There was one case of locally recurrent disease, and one death meaning that disease-free survival was 96%, and overall survival was 96% (22/23) at a mean follow-up of 35.4 months. CONCLUSIONS: Transhiatal oesophagectomy for high-grade dysplasia can be performed with acceptable mortality and morbidity when performed at a specialist centre.

Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre.

INTRODUCTION: The aim of this study was to review the management and outcome of patients with Boerhaave's syndrome in a specialist centre between 2000-2007. PATIENTS AND METHODS: Patients were grouped according to time from symptoms to referral (early, < 24 h; late, > 24 h). The effects of referral time and management on outcomes (oesophageal leak, reoperation and mortality) were evaluated. RESULTS: Of 21 patients (early 10; late 11), three were unfit for surgery. Of the remaining 18, immediate surgery was performed in 8/8 referred early and 6/10 referred late. Four patients referred late were treated conservatively. Oesophageal leak (78% versus 12.5%; P < 0.05) and mortality (40% versus 0%; P < 0.05) rates were higher in patients referred late. For patients referred late, mortality was higher in patients managed conservatively (75% versus 17%; not significant). CONCLUSIONS: The best outcomes in Boerhaave's syndrome are associated with early referral and surgical management in a specialist centre. Surgery appears to be superior to conservative treatment for patients referred late.

The role of oesophageal diversion and exclusion in the management of oesophageal perforations.

AIM: Persistent sepsis from an oesophageal perforation has a near 100% mortality. We describe our experience with early oesophageal diversion and exclusion for patients in-extremis. METHODS: A retrospective review of oesophageal perforations was performed between 2000 and 2007. There were five cases Boerhaaves and one case of iatrogenic perforation that required oesophageal diversion and exclusion. 4 males, 2 females with a mean age of 67.6 (58-72) years. RESULTS: The primary procedure was performed within 24h in four patients; the other two were after 3 and 10 days. The intensive care unit (ITU) stay was a median of 25 days. Mortality rate was 50%. Median length of stay for the survivors was 60 days. Three patients underwent a successful colonic interposition in our unit after 6 months. CONCLUSION: Exclusion and diversion procedures are required in very rare circumstances. In conditions of persistent leak and continuing sepsis or those patients not fit to undergo a major procedure they could be lifesaving if performed early. As it is a relatively easy and quick procedure it should be considered early as a 2nd line management option.

Surgical management of late complications after colonic interposition for esophageal atresia.

Late complications after colonic interposition for neonatal esophageal atresia may lead to debilitating symptoms, poor quality of life, and malnutrition in young adults with otherwise normal life expectancies. We report our experience with 3 patients who underwent revision surgery more than 20 years after colonic interposition. Revision surgery may relieve symptoms and improve quality of life in selected patients. However, for patients with recurrent symptoms, further reconstructive options may be limited due to the lack of an available conduit, and long-term enteral feeding may be the only option for these patients.

Bilateral retrovascular femoral hernia.

A 34-year-old woman with cystic fibrosis presented with bilateral femoral hernias, which were found to be retrovascular at operation. The hernias were not amenable to conventional open or laparoscopic repair, and were repaired using pre-peritoneal mesh inserted deep to transversalis fascia. The anatomical basis and management of uncommon variants of femoral hernia are discussed.

Recurrent laryngeal nerve palsy due to impacted dental plate in the thoracic oesophagus: case report.

BACKGROUND: Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus. CASE PRESENTATION: We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body. CONCLUSION: Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.

Laparoendoscopic management of gastrointestinal stromal tumors.

Gastrointestinal stromal tumors (GISTs) account for 1% to 3% of all resected gastric tumors and are the most common submucosal mass found in the stomach. The preoperative characterization of malignancy is often difficult, and excision is the most common management option. Reported techniques are endoscopic, laparoendoscopic, and laparoscopic. The excision can be intracorporeal or extracorporeal, intragastric or transgastric. Different methods are used based on the location of the tumor. We present two cases of a three-port laparoendoscopic transgastric technique. This method can be used safely for both anteriorly and posteriorly located lesions.