Single-centre review of the management of intra-thoracic oesophageal perforation in a tertiary oesophageal unit: paradigm shift, short- and long-term outcomes over 15 years.

BACKGROUND: Oesophageal perforation is an uncommon surgical emergency associated with high morbidity and mortality. The timing and type of intervention is crucial and there has been a major paradigm shift towards minimal invasive management over the last 15 years. Herein, we review our management of spontaneous and iatrogenic oesophageal perforations and assess the short- and long-term outcomes. METHODS: We performed a retrospective review of consecutive patients presenting with intra-thoracic oesophageal perforation between January 2004 and Dec 2020 in a single tertiary hospital. RESULTS: Seventy-four patients were identified with oesophageal perforations: 58.1% were male; mean age of 68.28 ± 13.67 years. Aetiology was spontaneous in 42 (56.76%), iatrogenic in 29 (39.2%) and foreign body ingestion/related to trauma in 3 (4.1%). The diagnosis was delayed in 29 (39.2%) cases for longer than 24 h. There was change in the primary diagnostic modality over the period of this study with CT being used for diagnosis for 19 of 20 patients (95%). Initial management of the oesophageal perforation included a surgical intervention in 34 [45.9%; primary closure in 28 (37.8%), resection in 6 (8.1%)], endoscopic stenting in 18 (24.3%) and conservative management in 22 (29.7%) patients. On multivariate analysis, there was an effect of pathology (malignant vs. benign; p = 0.003) and surgical treatment as first line (p = 0.048) on 90-day mortality. However, at 1-year and overall follow-up, time to presentation (≤ 24 h vs. > 24 h) remained the only significant variable (p = 0.017 & p = 0.02, respectively). CONCLUSION: Oesophageal perforation remains a condition with high mortality. The paradigm shift in our tertiary unit suggests the more liberal use of CT to establish an earlier diagnosis and a higher rate of oesophageal stenting as a primary management option for iatrogenic perforations. Time to diagnosis and management continues to be the most critical variable in the overall outcome.

Development of consensus-derived quality indicators for laparoscopic sleeve gastrectomy operative reports.

BACKGROUND: Synoptic operative reporting has been used as a solution to the poor quality of narrative reports. The aim of this study was to develop operative report quality indicators for the laparoscopic sleeve gastrectomy and to generate parameters by which these reports can be evaluated and improved. METHODS: A Delphi protocol was used to determine quality indicators for LSG. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Transferrable consensus items for LSG from previously developed Roux-en-Y gastric bypass operative indictors were put forward for consideration. Participants also initially submitted potential QIs. These were grouped by theme. Items were rated on 5-point Likert scales in subsequent rounds. Scores of 70% or higher were used for inclusion and 30% or less denoted exclusion. Elements scoring 30% to 70% agreement were recirculated by runoff in subsequent rounds to generate the final list of quality indicators. RESULTS: Seven bariatric surgeons, representing all regions preforming LSG in Canada, were invited to participate in the Delphi group. Multidisciplinary invitees included one academic minimally invasive/acute care surgeon, one tertiary abdominal radiologist, and one academic gastroenterologist with bariatric expertise. Two rounds were required to achieve consensus. Both rounds achieved a 100% response (10/10). In round 1, forty items reached consensus. In Round 2, an additional 28 items reached consensus, with three items excluded, bringing the total number of quality indicators to 65. CONCLUSION: This study establishes consensus-derived multidisciplinary quality indicators for LSG operative reports. Application of these findings aims to advance the quality and completeness of operative reporting in LSG in order to improve communication of important surgical details and quality measures to the multidisciplinary team involved in bariatric surgery care.

Ultrasound Guided Laparoscopic Port Placement in a Patient with Congenital Anomaly of IVC Undergoing Sleeve Gastrectomy.

We report a patient with obesity who underwent laparoscopic sleeve gastrectomy after pre-operative ultrasound mark up to enable safe port insertion due to presence of venous collaterals in the abdominal wall as a result of congenial IVC anomaly. This patient was falsely presumed to have NASH cirrhosis. Detailed preoperative workup ruled this out and led to the discovery of congenital IVC anomaly as the cause of engorged blood vessels in the anterior abdominal wall. On table ultrasound mark up of safe sites for port insertion enabled a safe laparosocpic sleeve gastrectomy on this patient.

A systematic review of the effect of gastric pouch and/or gastrojejunostomy (stoma) size on weight loss outcomes with Roux-en-Y gastric bypass.

BACKGROUND: The effect of the gastric pouch or Gastrojejunostomy (GJ or stoma) size on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) is unclear with studies reporting conflicting results. The purpose of this systematic review was to determine the impact of the gastric pouch or stoma size on weight loss outcomes with RYGB. METHODS: An online search of PubMed was carried out to identify all articles evaluating the effect of the gastric pouch and/or gastric stoma size at the time of surgery on outcomes associated with RYGB. Quality and heterogeneity of data precluded a meta-analysis. So a systematic review was performed without a meta-analysis. RESULTS: This review found a total of 14 studies (two of which were randomised) evaluating the effect of pouch sizes on weight loss outcomes after RYGB. Nine of these studies did not find any significant association between pouch size and weight loss outcomes whereas five studies found larger pouches to be associated with poorer weight loss outcomes. No study found larger pouches to be associated with better weight loss outcomes. Out of the ten studies (one of which was randomised) that evaluated the effect of stoma size on weight loss outcomes after RYGB, six studies did not show any significant effect of stoma size on weight loss outcomes and four found larger stoma sizes to be associated with significantly poorer weight loss outcomes. No study found larger stoma to be associated with better weight loss outcomes. CONCLUSIONS: This review finds that a larger pouch or stoma size may be associated with adverse weight loss outcomes but the quality of data does not allow us to precisely determine optimum pouch or stoma size with RYGB. There is a need for more randomised data comparing long-term weight loss outcomes with pouches or stoma of different sizes.

Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Long-Term Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) has overtaken Roux-En-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide. However, there is little long-term data comparing the two procedures. OBJECTIVES: We perform a systematic review and meta-analysis comparing 5-year outcomes of randomised controlled trials (RCTs) comparing RYGB and SG. METHODS: Medline, Embase, The Cochrane Library, and NHS Evidence were searched for English language RCTs comparing RYGB with SG and assessed weight loss and/or comorbidity resolution at 5 years. RESULTS: Five studies were included in the final analysis. Meta-analysis demonstrates a significantly greater percentage excess weight loss in patients undergoing RYGB compared with SG (65.7% vs 57.3%, p < 0.0001). Resolution of diabetes was seen in 37.4% and 27.5% after RYGB and SG respectively. There was no significant difference between RYGB and SG in rates of resolution or improvement of diabetes. Similarly, HbA1C levels were not significantly different between the two procedures. Resolution of dyslipidaemia was more common after RYGB (68.6% vs 55.2%, p = 0.0443). Remission of gastro-oesophageal reflux occurred in 60.4% in the RYGB group in contrast to 25.0% in the SG group (p = 0.002). CONCLUSIONS: Both RYGB and SG result in sustained weight loss and comorbidity control at 5 years. RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD).

Effect of Roux-en-Y gastric bypass on pharmacologic dependence in obese patients with type 2 diabetes

Background: More than half the diabetes-related health care costs in Canada relate to drug costs. We aimed to determine the effect of Roux-en-Y gastric bypass (RYGB) on the use of insulin and orally administered hypoglycemic medications in patients with diabetes. We also looked to determine overall cost savings with the procedure. Methods: We reviewed the bariatric clinic records of all patients with a confirmed diagnosis of type 2 diabetes mellitus who underwent RYGB between 2010/11 and 2014/15. Percentage estimated weight loss was recorded at 1 year, along with reductions in glycated hemoglobin (HbA1c) level and use of oral hypoglycemic therapy and insulin. We estimated medication costs using Manitoba-specific pricing data. Results: Fifty-two patients with at least 12 months of complete follow-up data were identified. The mean percentage estimated weight loss was 50.2%. The mean HbA1c level decreased from 7.6% to 6.0%, the mean number of orally administered hypoglycemics declined from 1.6 to 0.2, and the number of patients receiving insulin decreased from 18 (35%) to 3 (6%) (all p < 0.001). The rate of resolution of type 2 diabetes was 71%. Estimated mean annual per-patient medication costs decreased from $508.56 to $79.17 (p < 0.001). Potential overall health care savings could total $3769 per patient in the first year, decreasing to $1734 at 10 years. Conclusion: Roux-en-Y gastric bypass resulted in significant improvement in diabetic control, with a reduction in hypoglycemic medication use and associated costs in the early postoperative period. Potentially, large indirect and direct cost savings can be realized in the longer term.

Contexte: Plus de la moitié des coûts des soins de santé liés au diabète au Canada sont générés par les médicaments. Nous avons voulu déterminer l'effet de la dérivation gastrique de Roux-en-Y sur l'utilisation des agents hypoglycémiants oraux et de l'insuline chez les patients diabétiques. Nous avons aussi cherché à déterminer l'ensemble des économies associées à cette intervention. Méthodes: Nous avons passé en revue les dossiers cliniques bariatriques de tous les patients ayant un diagnostic confirmé de diabète de type 2 qui ont subi une dérivation gastrique de Roux-en-Y entre 2010­2011 et 2014­2015. La perte de poids ­ estimée en pourcentage ­ a été notée après un an, ainsi que les réductions des taux d'hémoglobine glyquée (HbA1c) et du recours aux hypoglycémiants oraux et à l'insuline. Nous avons estimé les coûts des médicaments à partir des données de tarification du Manitoba. Résultats: Cinquante-deux patients pour lesquels on disposait d'au moins 12 mois de données de suivi complètes ont été retenus. La perte de poids moyenne estimée en pourcentage était de 50,2 %. Le taux moyen d'HbA1c a diminué de 7,6 % à 6,0 %, le nombre moyen de comprimés d'hypoglycémiants oraux est passé de 1,6 à 0,2, et le nombre de patients sous insuline a diminué de 18 (35 %) à 3 (6 %) (tous p < 0,001). Le taux de résolution du diabète de type 2 était de 71 %. Le coût annuel moyen estimé des médicaments par patient est passé de 508,56 $ à 79,17 $ (p < 0,001). Les économies potentielles globales pour le système de santé pourraient totaliser 3769 $ par patient au cours de la première année, puis passer graduellement à 1734 $ au cours des 10 années suivantes. Conclusion: La dérivation gastrique de Roux-en-Y a permis d'améliorer significativement le contrôle du diabète, ainsi que de réduire le recours aux hypoglycémiants et les coûts associés au début de la période postopératoire. À plus long terme, d'importantes économies sur le plan des coûts indirects et directs pourraient potentiellement être réalisées.

Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience.

BACKGROUND: Laparoscopic Roux Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed bariatric procedures. Improvement in techniques and perioperative management of patients have resulted in shorter hospital stay and reduced overall costs. Many post-operative protocols aspire to post-operative day 1 discharge with studies showing reduction in length of stay without increasing complications. In this study, we investigate the factors predictive of early discharge at our high-volume bariatric centre. METHODS: A retrospective review of all patients who underwent bariatric surgery (RYGB or SG) at a single centre between January 2013 and December 2014 was undertaken. Routine preoperative investigations were performed and patient discussed at bariatric MDT. Post-operative management was as per standard protocols. Demographic data, type of surgery and post-operative data (length of stay, complications, readmission, reoperations) were analysed. Statistical analysis was performed using SPSS. RESULTS: Five hundred six patients underwent RYGB (407 (80.4%)) or SG (99 (19.6%)). The mean preoperative BMI was 45.9 (range 33.3-80.6). The median length of stay was 1 day (range 1-214 days; interquartile range 1-2 days) for RYGB and 2 days (range 1-8 days; interquartile range 1-3 days) for SG. Two hundred sixty-eight (52.9%) patients were discharged on post-operative day 1. The type of surgery and preoperative BMI were the only significant factors predicative of day 1 discharge after surgery. Patients undergoing SG were 3.3 times more likely to stay longer than 1 day after surgery (p < 0.001). BMI < 50 is associated with day 1 discharge (p = 0.030). CONCLUSION: Early discharge, on post-operative day 1 appears to be safe and is not associated with a greater risk of readmission. Sleeve gastrectomy and a BMI > 50 are associated with an increased risk of failure to achieve day 1 discharge.

Systematic review and retrospective validation of prediction models for weight loss after bariatric surgery.

BACKGROUND: Patients often have less than realistic expectations of the weight loss they are likely to achieve after bariatric surgery. It would be useful to have a well-validated prediction tool that could give patients a realistic estimate of their expected weight loss. OBJECTIVES: To perform a systematic review of the literature to identify existing prediction models and attempt to validate these models. SETTING: University hospital, United Kingdom. METHODS: A systematic review was performed. All English language studies were included if they used data to create a prediction model for postoperative weight loss after bariatric surgery. These models were then tested on patients undergoing bariatric surgery between January 1, 2013 and December 31, 2014 within our unit. RESULTS: An initial literature search produced 446 results, of which only 4 were included in the final review. Our study population included 317 patients. Mean preoperative body mass index was 46.1 ± 7.1. For 257 (81.1%) patients, 12-month follow-up was available, and mean body mass index and percentage excess weight loss at 12 months was 33.0 ± 6.7 and 66.1% ± 23.7%, respectively. All 4 of the prediction models significantly overestimated the amount of weight loss achieved by patients. The best performing prediction model in our series produced a correlation coefficient (R2) of .61 and an area under the curve of .71 on receiver operating curve analysis. CONCLUSIONS: All prediction models overestimated weight loss after bariatric surgery in our cohort. There is a need to develop better procedures and patient-specific models for better patient counselling.

Contribution of Malabsorption to Weight Loss After Roux-en-Y Gastric Bypass: a Systematic Review.

Roux-en-Y gastric bypass (RYGB) is traditionally classified as a combined restrictive and malabsorptive operation. This notion of the operation influences its technical variations and revisions for patients who do not achieve significant weight loss after this surgery. There is an increasing body of literature suggesting a role for appetite suppression mediated by neuro-hormonal signals after RYGB. The purpose of this paper was to systematically review published English language scientific literature to determine the role of malabsorption towards weight loss achieved with RYGB. This review finds that there is little or no malabsorption of carbohydrates or protein after RYGB but there is some fat malabsorption. Overall, malabsorption makes a little (approximately 11.0% in the early period) overall contribution to weight loss after RYGB.

Systematic Review and Meta-Analysis of Outcomes After Revisional Bariatric Surgery Following a Failed Adjustable Gastric Band.

INTRODUCTION: Laparoscopic adjustable gastric band (LAGB)-related complications have been reported in significant numbers of patients often leading to band removal. Increasingly revisional bariatric surgery (RBS) is offered, most commonly either band to Roux-en-Y gastric bypass (B-RYGB) or band to sleeve gastrectomy (B-SG). OBJECTIVES: We conducted a systematic review and meta-analysis of studies to evaluate the efficacy of RBS following failed LAGB. METHODS: Medline, Embase, The Cochrane Library and NHS Evidence were searched for English language studies assessing patients who had undergone LAGB and who subsequently underwent either B-RYGB or B-SG. RESULTS: Thirty-six studies met the inclusion criteria. There were 2617 patients. B-RYGB was performed in 60.5% (n = 1583). There was one death within 30 days (0.0004%). The overall pooled morbidity rate was 13.2%. There was no difference between the B-RYGB and B-SG groups in morbidity, leak rate or return to theatre. Percentage excess weight loss (%EWL) following the revisional procedure for all patients combined at 6, 12 and 24 months was 44.5, 55.7 and 59.7%, respectively. There was no statistical difference in %EWL between B-RYGB and B-SG at any time point. The rates of remission of diabetes, hypertension and obstructive sleep apnoea were 46.5, 35.9 and 80.8%, respectively. CONCLUSIONS: Randomised controlled trials (RCTs) do not exist on this issue but the available observational evidence does suggest that RBS is associated with generally good outcomes similar to those experienced after primary surgery. Further, high-quality research, particularly RCTs, is required to assess long-term weight loss, comorbidity and quality of life outcomes.

Systematic Review and Meta-Analysis of Occupational Outcomes after Bariatric Surgery.

INTRODUCTION: Obesity has been linked with reduced productivity in the workplace and is associated with higher levels of unemployment and absenteeism. Studies have shown improvement in functioning and enhanced activity levels in patients after bariatric surgery. OBJECTIVES: We perform a systematic review and meta-analysis of the literature to assess the impact of bariatric surgery on occupational outcomes. METHODS: Medline, Embase, The Cochrane Library and NHS Evidence were searched for English language studies assessing factors related to employment both preoperatively and postoperatively. RESULTS: The initial search produced 189 results. Ten studies met our inclusion criteria and were included in the review. Meta-analysis did not suggest a significant improvement in overall employment rates after surgery (RR 1.058, p = 0.155). However, pooled analysis of studies analysing unemployed patients separately demonstrates that 26.4 % (95 % CI 21.6-31.5 %) of unemployed patients are able to return to work after bariatric surgery. Pooled analysis on two studies suggests that those undergoing surgery are 3.24 (p = 0.01) times more likely to return to work than non-surgical controls. Three studies demonstrated significant reductions in the mean number of annual sick days. CONCLUSIONS: There is limited evidence in the literature regarding occupational outcomes following bariatric surgery, and further studies are required before firm conclusions can be drawn. However, the existing evidence does suggest that bariatric surgery has a generally positive impact on occupational outcomes. This suggests that surgery may have wider economic, social and psychological benefits above and beyond its immediate health benefits.

Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review.

INTRODUCTION: Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma. MATERIALS AND METHODS: A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity. RESULTS: Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan. CONCLUSIONS: Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.

Vein graft aneurysms following popliteal aneurysm repair are more common than we think.

True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts (P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance.

Multilevel bypass grafting: is it worth it?

BACKGROUND: Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years. METHODS: We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital. RESULTS: There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures. CONCLUSIONS: Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.

Massive gastric dilation complicating diabetic gastroparesis.

A middle-aged man presented at 4:00 with tense distended abdomen, severe pain and numb legs. His medical background included poorly controlled insulin-dependent diabetes. Abdominal x-ray showed a massively distended, featureless viscus on the left side of the abdomen thought to be a sigmoid volvulus. CT scan was delayed due to respiratory compromise from diaphragmatic splinting. Nasogastric and flatus tube decompression were attempted. Eventually CT was obtained and provisionally reported as a sigmoid volvulus. Emergency laparotomy was performed due to the risk of impending perforation. Operative findings were of a hugely distended stomach extending into the left iliac fossa almost completely occupying the abdominal cavity. Gastrotomy was used to decompress the stomach. No mechanical obstruction was identified. Postoperatively he had an episode of massive haematemesis thought to be due to sloughing of gastric mucosa. He was taken back to theatre and died on table.

Back to basics--cutting the cord on umbilical infections.

INTRODUCTION: Surgical site infections (SSIs) are a significant cause of postoperative morbidity with laparoscopic surgery associated with lower SSI rates. However, a departmental change in our unit to increased laparoscopic colorectal surgery resulted in increased wound infection rates at umbilical specimen extraction sites, the cause of which we attempted to elucidate. SUBJECTS AND METHODS: Prospectively collected data over an 18-month period (April 2008 to September 2009) for laparoscopic colorectal operations in a busy teaching hospital were retrospectively analysed, focusing on operation performed, whether pre-operative skin cleansing was employed, nature of specimen extraction excision, and rate of umbilical wound infection. Comparison was made with open colorectal procedures performed in the preceding year. RESULTS: In total, 275 laparoscopic colorectal operations were performed. Over the first 8 months there was a significant increase in infection rates when compared with open procedures over a similar time period (23.5% vs 8.0%; P = 0.0001). Changing practice to use pre-operative skin cleansing and an incision that skirted around, as opposed to traversing, the umbilicus reduced umbilical infection rates significantly from 23.5% to 11.6% (P = 0.01). Patients undergoing right hemicolectomy benefitted more (reduction of 30.0% to 6.9%; P = 0.04) than those undergoing anterior resection (26.8% vs 15.6%, P = 0.13). CONCLUSIONS: Umbilical incisions, when extended for specimen extraction, are particularly prone to infection following colorectal surgery but rates can be reduced by simple measures such as pre-operative umbilical cleansing and avoidance of the umbilicus in the incision, without the need for drastic and costly changes in technique or antibiotic prophylaxis.

Meckel diverticulum causing small bowel obstruction.

A 62-year-old man was admitted with generalised abdominal pain, constipation and vomiting. His abdomen was markedly distended and tender on general examination with signs of local peritonism in the left iliac fossa. He was initially diagnosed with likely acute diverticulitis and treated conservatively. A CT scan the next day showed fluid filled, dilated small bowel loops consistent with small bowel obstruction and there was a suggestion of an abscess in the left iliac fossa region. An urgent laparotomy was performed, which identified a perforated Meckel diverticulum.