What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION: Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center. METHODS: We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC. RESULTS: Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone. CONCLUSIONS: PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Acute pancreatitis in the elderly - Can we perform better?

BACKGROUND: Despite age traditionally being a criterion for stratification of severity in acute pancreatitis (AP), the condition is not common in the elderly population (>80 years) and very few studies have examined outcome in this cohort. The aim of this study was to evaluate our experience and outcome in this expanding population. METHODS: A retrospective analysis was performed of all patients over 80 years of age who were admitted with AP (defined as a serum amylase >400 IU/L) between January 2004 and January 2007. The modified Glasgow score was used for severity stratification. RESULTS: Forty patients with AP were admitted during the study period, of whom 23 were females. The mean age was 84 (SD 4.1) years. Fifteen patients (37%) had severe AP as indicated by a Glasgow score of 3 or more. The aetiologies were gallstones (n = 28; 70%), drug-induced (n = 4; 10%) and idiopathic (n = 8; 20%). Ten patients (25%) died during their initial admission to hospital, of whom 5 died before undergoing any form of imaging to determine the cause of AP. Six patients, 5 of whom had gallstones were subsequently readmitted with a further attack of AP. Eleven patients underwent an ERCP during their initial admission and a further 4 patients underwent ERCP during their subsequent admission. Only 3 patients with gallstone-induced AP underwent a cholecystectomy, all performed laparoscopically. CONCLUSIONS: AP in octogenarians is a significant problem and carries a high mortality irrespective of the Glasgow severity score. Early intervention by means of ERCP is indicated to try and improve outcome in this group with biliary pancreatitis. Laparoscopic cholecystectomy must be considered as a definitive treatment in these patients as available evidence suggests that this can be performed with acceptable morbidity and mortality in this group.

Outcomes of intensive surveillance after resection of hepatic colorectal metastases.

BACKGROUND: The impact of computed tomography (CT)-based follow-up for the detection of resectable disease recurrence following surgery for colorectal liver metastases (CRLM) was evaluated. METHODS: Some 705 patients undergoing resection of CRLM between January 1993 and March 2007 were included. Surveillance comprised 3-monthly CT (thorax, abdomen and pelvis) in the first 2 years after surgery, 6 monthly for 3 years and annually from years 6 to 10. Survival differences following recurrence between patients managed surgically and palliatively were determined, and the cost was calculated. RESULTS: Five-year disease-free and overall survival rates were 28.3 and 32.3 per cent respectively. Of 402 patients who developed recurrence within 2 years, 88 were treated with liver resection alone and 36 with lung and/or liver resection. Their 5-year overall survival rates were 31 and 30 per cent respectively, compared with 3.9 per cent in 278 patients managed palliatively (P < 0.001). For each 3-month interval during the first year of follow-up, patients with recurrence treated surgically had better overall survival than those treated palliatively. The cost of surveillance that identified 124 patients amenable to further resection was 12,338 pounds per operated recurrence. Assuming that patients with recurrence gained 5 years' survival, the mean survival gain was 4.28 years per resection and the cost per life-year gained was 2883 pounds. CONCLUSION: Intensive 3-monthly CT surveillance after liver resection for CRLM detects recurrence that is amenable to further resection in a considerable number of patients. These patients have significantly better survival with a reasonable cost per life-year gained.

Cholangiocarcinoma complicating primary sclerosing cholangitis: a 24-year experience.

AIM: To report the prevalence and outcome of cholangiocarcinoma arising in primary sclerosing cholangitis for a British tertiary referral centre. METHODS: All patients diagnosed with primary sclerosing cholangitis and concurrent cholangiocarcinoma were identified from a prospectively maintained departmental database, and the mode of presentation, management and outcome were determined. RESULTS: Of 370 patients with primary sclerosing cholangitis, 48 patients (13%) were diagnosed with a cholangiocarcinoma within a median time of 0.51 months (range: 0-73.12) from presentation to the unit. Mode of presentation included: inoperable tumours (n = 14); incidental findings in transplant hepatectomy specimens (n = 13); primary sclerosing cholangitis follow-up (n = 9); transplant work-up (n = 5); transplant waiting list (n = 5); suspected tumour confirmed at transplant (n = 1), and incidental finding at cholecystectomy (n = 1). The diagnosis was confirmed by: radiology-guided biopsy (n = 27); MRI (n = 3); CT (n = 2); laparoscopy or laparotomy (n = 2), and frozen section at transplant (n = 1). Management consisted of: transplantation (n = 14, including 1 abandoned); hepatic resection (n = 8), and palliation through stenting (n = 26). The overall median survival of the cohort was 4.9 months (range: 0.09-104.5). Median survival ranged from 2.6 months (range: 0.09-35.3) for palliation to 7.6 months (range: 0.6-99.6) for transplantation and 52.8 months (range: 3.7-104.5) for resection. There was no difference in survival between the transplant and resection groups (p = 0.14). CONCLUSIONS: Cholangiocarcinoma is a common finding in primary sclerosing cholangitis and regular screening of this cohort of patients at referring centres is advocated to detect early tumours, as surgical treatment at an early stage offers significantly better outcomes for this cohort of patients.

Laparoscopic paraoesophageal hernia repair: fundoplication is not usually indicated.

BACKGROUND: Paraoesophageal hernias are an uncommon but important diaphragmatic defect due to a high prevalence of associated complications. The advent of laparoscopic surgery has popularised the surgical management of this condition, although the optimal technique has yet to be defined. The aim of this cohort study was to assess the necessity of an anti-reflux procedure in addition to the crural repair. METHODS: Details of all patients undergoing laparoscopic paraoesophageal hernia repair were collected prospectively paying particular attention to the details of the operative procedure and outcome, including the development of early complications. All patients were followed for six months and symptoms related to hernia recurrence or technical failure including dysphagia and reflux were noted. RESULTS: Twenty-three consecutive patients underwent laparoscopic paraoesophageal hernia repair. The first 11 patients (Group 1) routinely underwent an additional anti-reflux procedure, whereas the later cohort (Group 2) did not (chi-squared P<0.05). At six months, nine of eleven patients in Group 1 reported dysphagia, in two cases requiring dilatation, but this complication was not seen in those in Group 2. Two patients reported reflux at six-month follow-up; this was controlled in both cases by a low dose of a proton pump inhibitor. CONCLUSION: Laparoscopic repair of paraoesophageal hernias is an effective treatment with excellent short-term results and no recurrences. Our experience would suggest that an anti-reflux procedure is not always indicated and may indeed be detrimental to symptomatic outcome.

Hernioscopy: a useful technique for the evaluation of incarcerated hernias that retract under anaesthesia.

INTRODUCTION: The diagnosis of strangulation within an incarcerated abdominal-wall hernia is not always possible preoperatively. In approximately 1% of cases of incarcerated hernias, a strangulated viscus will reduce spontaneously following administration of muscle relaxants during induction of anaesthesia, and the surgeon has to perform an exploratory laparotomy. The aim of this study was to report the use of hernioscopy to inspect intra-abdominal contents and thus prevent unnecessary laparotomy. PATIENTS AND METHODS: The case notes of all patients undergoing hernioscopy for incarcerated hernias that reduced spontaneously during induction of anaesthesia, skin incision, or prior to evaluation of sac contents were reviewed. Hernioscopy is performed following insertion of a 10-mm port through the hernia sac. Standard insufflation with carbon dioxide is performed, maintaining an intra-abdominal pressure of 10-12 mmHg following which the laparoscope is inserted and a diagnostic examination performed. Following completion of hernioscopy, the laparoscope is withdrawn, the pneumoperitoneum released, and the hernia repaired in a conventional manner using a tension-free technique. RESULTS: Five patients underwent hernioscopy for the evaluation of incarcerated hernias that had reduced spontaneously prior to inspection of sac contents. There were four men with indirect inguinal hernias and one woman with an incarcerated femoral hernia. The hernioscopy of the four men was unremarkable and they went home the following day. The female patient had blood within the peritoneal cavity arising from the upper abdomen and underwent laparotomy and splenectomy. She made an unremarkable recovery and was discharged on postoperative day 7. CONCLUSION: Hernioscopy is a simple and useful technique that can be performed by surgeons familiar with laparoscopic procedures such as appendicectomy and cholecystectomy.

Prioritisation of vascular outpatient appointments cannot be based on referral letters alone.

BACKGROUND: Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. OBJECTIVE: We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. MATERIAL AND METHODS: All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. RESULTS: Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001). CONCLUSION: Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.

Management of cardiovascular risk factors by primary care physicians in patients with peripheral arterial disease.

BACKGROUND: Patients with significant coronary artery disease (CAD) are now intensively treated by primary care physicians predominantly because of government pressure and remuneration to prescribe anti-platelet and anti-hyperlipidaemic drugs. Peripheral arterial disease (PAD) with the identical risk factors appeared to us to be less intensively investigated and treated by primary care physicians. OBJECTIVE: To review the treatment of risk factors in all patients referred to two vascular clinics with a diagnosis of suspected PAD. DESIGN: Cross-sectional survey. SETTING: Vascular outpatient clinic in two district general hospitals. PARTICIPANTS: 124 consecutive new patients were studied to determine risk factors and appropriate treatment. RESULTS: Of the 124 patients, 85 (68%) were confirmed to have PAD without evidence of symptomatic CAD. In the PAD alone group, less than 25% received anti-smoking advice (p < 0.0001) and only 36% were prescribed anti-platelet drugs (p = 0.016). Seventy-three per cent of the overall referred patients with hypertension had been treated for this condition and the blood pressure was normal in 71% of the patients with PAD. In patients with hyperlipidaemia, statins had been prescribed in 92% of patients with coexistent symptomatic CAD, but only in 64% of patients with PAD alone (p = 0.009). In the patients with diabetes, only 66% of the PAD alone group had adequate control of their blood sugar (p = 0.185). CONCLUSIONS: It would appear that patients with CAD and PAD are being treated successfully for their risk factors, but patients with PAD alone, sharing the same common risk factors, are being less than optimally treated.

Atherosclerotic axillary artery aneurysm.

True aneurysms of the axillary artery are rare, most pulsatile masses in the region being pseudoaneurysms. The present study reports a case of a true atherosclerotic axillary artery aneurysm arising in a 65 year old lady which presented with a short history of a painless pulsatile mass and sensory defecit in the hand in the absence of limb trauma. Following preoperative imaging to determine the anatomic details, she underwent repair of the aneurysm and made an excellent symptomatic recovery.

Can carotid ultrasound predict plaque histopathology?

AIM: European and North American studies have confirmed the benefits of carotid endarterectomy for patients with symptomatic carotid artery stenoses >70%. However, the management of asymptomatic patients and those with lesser degrees of stenosis is less certain. Several studies have suggested that, for these subgroups, the targeting of potentially unstable plaques, may help to identify those most at risk of cerebrovascular accidents and thus most likely to benefit from surgery. The aim of this study was to correlate the ultrasound features of carotid artery stenosis with the histopathological findings of the carotid endarterectomy specimens in order to identify features which will allow preoperative identification of clinically unstable plaques. METHODS: Sixty consecutive patients with symptomatic, critical carotid stenosis were prospectively studied. Plaques were classified preoperatively into one of five types based on their echogenicity and were also assessed for irregularity and ulceration. These findings were then compared with the histopathological findings of the endarterectomy specimen. RESULTS: Of 33 plaques considered on ultrasound to be uniformly or predominantly echolucent (unstable), 27 were found to be largely fatty or haemorrhagic (PPV =82%). Of 17 plaques considered to be predominantly echogenic (stable) on ultrasound, 11 were found to be predominantly fibrotic (PPV = 65%). Correlation between ultrasound irregularity or ulceration and histopathology was poor. CONCLUSION: In routine clinical practice, ultrasound can identify with reasonable accuracy, plaques that are predominantly haemorrhagic or fatty, and therefore potentially unstable. This may have future implications in selection of patients for surgery.

The European Working Time Directive: One for all and all for one?

BACKGROUND: The European Working Time Directive (EWTD) became law in Britain on October 1, 1998. As a result, the maximum period that may be spent as a resident in hospitals is 56 hours per week and after August 2009, 48 hours per week. The aim of this study was to determine the views of senior house officers (SHOs), specialist registrars (SpRs), and general consultant surgeons (CONs) in Wales on the influence of the EWTD on surgical training and clinical experience. METHODS: In this cohort study, a postal questionnaire was sent to 150 SHOs in surgical specialties, 50 general surgical SpRs, and all 84 CONs in the Welsh Deanery. RESULTS: The response rates were 81%, 78%, and 71% for SHOs, SpRs, and CONs, respectively. The vast majorities at all grades (88% SHOs, 100% SpRs, and 96% CONs) were unhappy with the introduction of EWTD legislation to clinical medicine. Most felt that EWTD legislation will have a negative effect on clinical experience (96% SHOs, 97% SpRs, 96% CONs); patient care (83% SHOs, 85% SpRs, 96% CONs); and training (94% SHOs, 100% SpRs, 93% CONs). Furthermore, a large proportion felt surgical training should be exempt from EWTD regulations (76% SHOs, 87% SpRs, 89% CONs). A significant proportion at each grade was opposed to the introduction of shifts in order to comply with regulations (78% SHOs, 87% SpRs, 89% CONs), and an alarming number have considered leaving the National Health Service when the regulations are enforced (29% SHOs, 41% SpRs, 33% CONs). CONCLUSION: This study shows that, in Wales at least, a vast majority of surgical trainees and consultants alike are opposed to the introduction of the EWTD and believe it will have a detrimental effect on training, patient care, and doctors' lives outside of medicine.

Is selenium deficiency an important risk factor for chronic graft nephropathy? A pilot study.

BACKGROUND: Lipid peroxidation by free radicals is a key step in the development of atherosclerosis. Chronic graft nephropathy (CGN) is a common cause of allograft failure and shares many histologic features with atherosclerosis. Although hyperlipidemia is a common finding in renal transplant recipients, not all patients develop CGN. We hypothesized that the degree of damage sustained is related to recipient antioxidant status and that only those who are antioxidant deficient succumb to free radical attack and develop CGN. We aimed to determine the antioxidant profiles of patients with biopsy-proven CGN and to compare their profiles to transplant patients with good renal function. METHODS: Plasma selenium and vitamin A and E concentrations were measured in 10 patients with CGN and 10 contemporaneous, sex-matched patients with normal renal graft function, who received the same immunosuppressive therapy. RESULTS: Patients with CGN had significantly lower plasma selenium concentrations compared with those with normal renal allograft function (P<0.05). There were no significant differences in plasma vitamin A or E concentrations between the two groups. There was no difference in the prevalence of any of the immunologic or nonimmunologic risk factors: human leukocyte antigen mismatches, panel-reactive antibody status, number of rejection episodes, cold ischemic time, hyperlipidemia, hypertension, diabetes, and cytomegalovirus infection between the two groups. CONCLUSIONS: Patients with CGN have evidence of selenium deficiency, suggesting that impaired antioxidant status may contribute to the development of CGN.

Giant mature cyst formation following mesh repair of hernias: an underreported complication?

BACKGROUND: Numerous complications have been described following the implantation of synthetic meshes during hernia repair; one of the rarest, with only three reported cases, is giant mature fibrous cyst formation. Our clinical experience with this complication has led us to believe that it may be more common than previously thought. METHODS: Surgical operation notes and pathology archives were reviewed for the period January 1998-January 2002 to determine the prevalence of mature cyst formation following mesh repair of hernias. RESULTS: Out of 1100 hernia repair operations involving the use of synthetic meshes in our institution during the period of study, five developed histologically confirmed mature fibrous cysts giving a prevalence of 0.45% for this complication. CONCLUSION: The formation of a giant mature cyst following mesh repair of hernias is an underreported complication.

Registrar operating experience over a 15-year period: more, less or more or less the same?

BACKGROUND: Concerns have been raised on the effects that recent changes in junior doctor work patterns may have on the breadth and depth of operative exposure achieved during specialist registrar training. This study aimed to determine whether there was any justification for these concerns by assessing whether there have been significant changes in either the number of cases or the case mix operated upon by registrars over the course of the past fifteen years. METHODS: A retrospective review of theatre records was undertaken, looking at the caseload of the registrars working for the same two consultant surgeons at one district general hospital in four one-year periods (1986-7; 1991-2; 1998-9; 2001-2). The number, subspecialty, and time of each operation were recorded. RESULTS: Whilst operating experience for the first three periods of the study was static, the most recent assessment point has demonstrated a significant reduction in trainee routine operative experience and also a small reduction in the emergency workload performed by both firms. There was also a significant change in the elective case mixes corresponding to consultant sub-specialisation during this period. In addition, there were notable changes in the nature of the emergency workload and a reduction in the number of cases performed after midnight. CONCLUSION: SpRs trained during the Calman era appear to be gaining less operative experience than their predecessors in both the elective and emergency settings. With further changes in working patterns currently being implemented, major changes to SpR programmes are required if surgeons are to be adequately trained.

Gastroschisis and total intestinal atresia.

Gastroschisis is an uncommon condition which is now being detected at an earlier stage due to the use of routine antenatal ultrasound scanning. The presence of intestinal atresia secondary to impairment of the vascular supply is well recognised and is associated with a poorer outcome because of the potential for loss of bowel length. We report a case of gastroschisis in which there was resorption of the bowel and closure of the abdominal wall defect. At laparotomy there was total intestinal atresia.

The continuing challenge of parastomal hernia: failure of a novel polypropylene mesh repair.

In an attempt to reduce the high recurrence rate after repair of parastomal hernia, a technique was devised in which non-absorbable mesh was used to provide a permanent closure of the gap between the emerging bowel and abdominal wall. Seven patients were treated during the period 1990-1992. Five-year follow-up has given disappointing results, with recurrent hernia in 29% of cases and serious complications, including obstruction and dense adhesions to the intra-abdominal mesh, in 57% and a mesh-related abscess in 15% of cases. This study highlights a dual problem--failure of a carefully sutured mesh to maintain an occlusive position, and complications of the mesh itself. The poor results obtained with this technique together with the disappointing results with other methods described in the literature confirms that parastomal hernia presents a continuing challenge.

Simple technique for non-operative removal of ureteric stents after renal transplantation.

Ureteric stents are employed peroperatively in renal transplantation when there is actual or suspected damage to the donor ureter. We describe a simple technique of suturing the distal end of the stent to the tip of a urinary catheter at the time of construction of the ureteric anastomosis. The stent is simply removed by gentle traction on the urinary catheter. This method obviates the need for a minor operative procedure or exposure to ionising radiation, which are the techniques commonly utilised at present. The procedure is also applicable to reconstructive urological procedures in which short-term stenting may be required.

Issues of consent in renal transplantation.

BACKGROUND: Renal transplantation is a semi-elective procedure. The specific risks of surgery are well-known. Obtaining informed consent is a complex process made more complicated in transplantation by the long-term nature of some of the risks involved. METHODS: A questionnaire survey was conducted of consultant transplant surgeons to establish current practice regarding the levels of information and risks discussed as part of the consent process. RESULTS: Responses were received from 47 (76%) of consultants. Risks were discussed by a range of individuals. Pre-assessment clinics were used by 70% of units to start the process. Only 74% routinely discussed malignancy and only 75% the risks of cytomegalovirus infection. Risks with individual organs were discussed by 32 (68%)--particularly HLA match, cold ischaemia, sensitisation, donor age and caused of donor death. CONCLUSIONS: The current practice identified by this study falls broadly within General Medical Council guidelines on informed consent. There is wide variation in current practice which is highlighted and discussed in relation to case law and the levels of risk that a patient should expect to be informed of.