Neuromuscular and vascular hamartoma as an unusual cause of small bowel obstruction.

INTRODUCTION: Neuromuscular and vascular hamartoma (NMVH) is a rare, controversial lesion of the intestine, with only 23 cases reported in the English literature since its initial description in 1982. PRESENTATION OF CASE: A 59year old female suffering from longstanding Crohn's disease with chronic stricture presented with symptoms of small bowel obstruction. Contrast studies demonstrated massive dilatation of the proximal small bowel. Laparotomy identified a 5cm long stenotic segment of ileum, with grossly distended jejunum and ileum proximally. Pathology determined the stricture's aetiology as a neuromuscular and vascular hamartoma of the small intestine. DISCUSSION: NMVH is a benign lesion of hamartomatous origin. Its very existence is questionable due to histological similarities with several reactive pathologies, such as Crohn's and diaphragm diseases. CONCLUSION: NMVH could be confused with a spectrum of chronic inflammatory bowel conditions, but this report establishes it as a distinct cause of chronic bowel obstruction.

Is low serum albumin associated with postoperative complications in patients undergoing oesophagectomy for oesophageal malignancies?

A best evidence topic was written according to a structured protocol. The question addressed was: in patients undergoing oesophagectomy for oesophageal malignancy, is low serum albumin associated with postoperative complications? Altogether, 87 papers were found using the reported search, of which 16 demonstrated the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes 2 level 2 papers, 12 level 3 papers and 2 level 4 papers. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, anastomotic leak, respiratory and non-respiratory complications, and length of hospital stay. Eleven of the 16 papers found an association between low serum albumin and postoperative complications. Of these, one study showed that low serum albumin combined with low fibrinogen levels (FA score) was predictive of postoperative recurrence of oesophageal cancer. Another study showed that when combined with white cell count and C-reactive protein (CRP, NUn score), serum albumin had a high diagnostic accuracy for major complications after postoperative day 3. The largest study compared the in-hospital mortality in 7227 patients who underwent oesophageal surgery for malignancy. The percentage of in-hospital mortality was associated with low serum albumin (<15.0 vs >35.0 g/l, 21.0 vs 11.3%, P <0.001). Five of the 16 papers found no significant association between low serum albumin and postoperative complications. Of these papers, one showed that low serum albumin was not an independent risk factor, while four others found no association between low serum albumin with respiratory complications, anastomotic leak and postoperative mortality. Instead, these studies found other factors responsible for postoperative complications such as: CRP, smoking, disease duration, malnutrition and low T-cell levels. Taken together, while low serum albumin is associated with postoperative complications, opinion regarding the prognostic value of low serum albumin and nutritional support remains conflicted. Because of the confounding factors encountered in these studies, the clinician should consider the finding of low serum albumin in patients, together with disease and surgical factors to provide optimal care for these patients.

Evaluating informed consent for colonoscopy.

BACKGROUND: This study aimed to collect and analyze data on patient knowledge of colonoscopy and their preferences regarding the provision of information about the procedure. Specifically, how much detail patients know about different aspects of the procedure and through which methods they best understand risk are evaluated and demographic correlations identified. MATERIALS AND METHODS: The study sample consisted of colonoscopy patients from 2 colorectal surgeons and a gastroenterologist at St Vincent's Public Hospital, Sydney for the period August 1 to November 1, 2010. A voluntary questionnaire was performed in the waiting room before colonoscopy. The questionnaire collected data on patient demographics; patient-perceived knowledge of the procedure; and understanding and preferences of various communication formats. RESULTS: Measures of patient-perceived knowledge about colonoscopy were significantly lower than those that would be preferred by patients (P=0.002). Those with higher levels of education preferred communication of colonoscopy-related information via a leaflet form, whereas those with lower levels preferred verbal information from a doctor or nurse (P=0.049). The most preferred format for explaining the risk of perforation was the pie graph, followed by both the 1000-person pictograph and absolute risk ratios. CONCLUSIONS: Patients received suboptimal levels of information about colonoscopy compared with their preferences. Key areas for improvement include providing more understandable information about the risks of colonoscopy. A combination of written information, diagrams and graphs, and then a discussion of this information to check the understanding is likely to be most effective. Further research into the communication of risk, with larger groups of patients, is likely to help clinicians in gaining fully informed consent in all patients.

Referral pathways in colorectal cancer: an audit of surgeons's records.

PURPOSE: To explore the referral pathways of patients with newly diagnosed colorectal cancer to surgeons. METHOD: Australian surgeons from three states completed a questionnaire and their records were audited. RESULTS: Thirty-three surgeons provided data on 530 patients seen in the preceding 12 months. The median time between colonoscopy and first surgical consult was 10 days, with 19% of patients waiting more than 28 days. After adjustment for clustering, no surgeon factors were associated with the number of days between colonoscopy and surgery. A report back to the general practitioner (GP) was found in 78% of patients' records. This feedback varied between surgeons but none of the specific surgeon characteristics examined could explain this. CONCLUSION: Surgeons usually communicated with GP regardless of whether they were the referral source. However, communication with GP varied considerably among surgeons, with no evidence of a report to the GP in one-fifth of cases.

A safe technique for the insertion of the Hasson cannula.

BACKGROUND: Most techniques of Hasson cannula insertion still involve a significant risk of visceral or vascular damage. This is true even for the modified open techniques of cannulation. METHODS: A technique of sequential clipping and elevation of abdominal wall layers is described, which permits safer Hasson cannulation at the umbilicus or at other sites on the abdomen even in the presence of underlying adhesions. RESULTS: Eight hundred and seventy-six patients underwent laparoscopic cholecystectomy using this technique of Hasson cannulation. Forty-two of these patients had the cannula placed at other sites other than the umbilicus because of previous surgery and suspected adhesions. Using this technique there were no major complications. Specifically, this technique did not incur any cases of visceral or vascular damage. CONCLUSIONS: The technique of sequential clipping and elevation of all layers of the abdominal wall during the insertion of the Hasson cannula allows for safer entry into the peritoneal cavity.