Ano-coccygeal support in the treatment of idiopathic chronic posterior anal fissure: a prospective non-randomised controlled pilot trial.

BACKGROUND: Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure. METHODS: Fifty-three patients with confirmed chronic anal fissures were enrolled and assigned, based on their preference, to the test group and the control group. Each patient was reviewed after therapy, and follow-up was scheduled at 4, 6 and 8 weeks and at 6 months. RESULTS: The fissure healing rate was 100% in both groups. There were no statistically significant differences between the test group (n = 30, median age 42 years; range 20-71 years) and the control group (n = 22, median age 38 years; range 23-60 years) with regards to resolution of rectal bleeding at defaecation after 4 weeks (86.6 vs. 72.7%, p = 0.698), and by week 6, bleeding had resolved in 100% of patients in both groups. There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks (4.30 ± 0.79, 2.03 ± 0.80, 0.43 ± 0.50 vs. 3.50 ± 0.74, 1.68 ± 0.56, 0.50 ± 0.51, p = 0.054) and to time until complete healing of fissures (5.60 ± 1.52 weeks vs. 5.91 ± 1.57 weeks, p = 0.479). After continuous use of the ano-coccygeal support over 6 months, no patients in the test group had recurrent fissures. No complications were observed during the trial. CONCLUSIONS: Results of both methods were comparable and demonstrated that the ano-coccygeal support is at least as effective as LIS, without any short-term complications. Larger and randomised trials on the use of ano-coccygeal support for chronic anal fissures are awaited.

Non-operative management of perforated duodenal ulcer.

We describe the selective non-operative management of 34 patients who had an initial diagnosis of perforated duodenal ulcer made on acute presentation between 1984-1994 in our district surgical unit. Diagnosis of the condition was made on clinical grounds with the aid of an erect chest X-ray which demonstrated pneumoperitoneum in 28 patients (82 per cent). Six patients (18 per cent) who did not respond to non-operative treatment required surgical intervention; 3 patients had an unsealed duodenal ulcer perforation; 2 had a perforated benign gastric ulcer and 1 patient had acute gangrenous cholecystitis. The overall mortality and morbidity rate was 3 per cent and 35 per cent respectively. There were no documented reperforations over a mean follow-up period of 27 months. While these figures are acceptable and comparable with operative intervention for this condition, we do however stress the labour intensive methods and close clinical monitoring that is required to avoid morbid sequelae.

Malaysian orthopaedic surgeons' approach to venous thromboembolic disease prophylaxis: attitudes and practice.

PURPOSE: To survey Malaysian orthopaedic surgeons' attitudes to and use of venous thromboembolic disease prophylaxis. METHODS: A total of 144 orthopaedic surgeons from various governmental and private institutions responded to a questionnaire. RESULTS: Only slightly more than half of these surgeons considered venous thromboembolic disease as common a problem in Malaysia as in western countries. The majority of surgeons (91.0%) reported using prophylaxis selectively for patients based on various indicators such as risk grading of surgery, obesity, and malignancy etc. Bleeding tendencies were cited as the greatest fear against the use of pharmacological prophylaxis. Low-molecular-weight heparin appeared to be the most commonly used pharmacological prophylaxis, used either singly or in combination with other forms of prophylaxis. The majority of surgeons employed prophylaxis until their patients were mobile. CONCLUSION: There should be greater awareness among surgeons in Malaysia of the need for protection against venous thromboembolic disease. Current practice needs to be reviewed and further recommendations made for existing protocols.

Primary torsion of the greater omentum.

Primary or idiopathic greater omental torsion remains a rare cause of acute surgical abdomen in adults and children. The aetiology is as yet unknown and the treatment of choice, once diagnosis is established, is resection of the torted omentum. We report our experience with three such cases encountered over the last five years, two of which were diagnosed and subsequently managed laparoscopically. The performance of diagnostic laparoscopy for acute abdominal pain of an undetermined origin may lead to an increased detection of this condition and subsequent therapeutic intervention.

Spontaneous pneumoperitoneum associated with colonic pseudo-obstruction.

Pneumoperitoneum is almost always pathognomonic of a perforated abdominal viscus requiring urgent surgical intervention. Spontaneous or non-surgical pneumoperitoneum is a rare clinical condition arising secondary to abdominal, thoracic, gynaecologic or idiopathic causes. In addition to good clinical judgement, an important component in the management process is to rule out other causes of pneumoperitoneum by performing appropriate investigations. We describe a 60-year-old man who presented with clinical features of pseudo-obstruction, following an injury to his back which was compounded by hypokalaemia. Roentgenography revealed massive pneumoperitoneum and colonic distension. As there were no overt clinical features of peritonitis, the patient was managed conservatively with parenteral nutrition and close observation. A water-soluble contrast enema and computed tomography of the abdomen were of no help in identifying the cause of his pneumoperitoneum but were helpful in eliminating the presence of hollow viscus perforation or an obvious inflammatory focus. The aetiology of pneumoperitoneum in our patient was most likely due to dissection of air through the distended colonic wall, secondary to large bowel pseudo-obstruction. The diagnosis of spontaneous or non-surgical pneumoperitoneum is one of exclusion and we stress the importance of relying on clinical parameters when managing such patients conservatively.

Primary malignant melanoma of the oesophagus.

Primary malignant melanoma arising in the oesophagus is a rare condition with a dismal prognosis. The diagnosis is often made following surgical resection even though the endoscopic features may be pathognomonic. The classical treatment is oesophagectomy even though the advanced disease stage at the time of presentation and aggressive biological behaviour of the tumour usually results in a fatal outcome. We report the case of a male patient initially diagnosed with squamous oesophageal carcinoma and treated with conventional neo-adjuvant chemo-radiotherapy. Poor clinical and radiological response resulted in a review of the original histology confirming a diagnosis of primary malignant melanoma of the oesophagus. The subsequent alteration in management conferred the patient an improved quality of life. A short review of the literature on primary malignant melanoma of the oesophagus supplements this case report.

Ruptured ectopic pregnancy presenting as an irreducible inguinal hernia.

An inguinal hernia that suddenly becomes irreducible may be secondary to a variety of other underlying conditions which can occasionally mislead the attending surgeon. Benign, inflammatory or neoplastic processes, as well as surgical emergencies such as intraperitoneal or retroperitoneal haemorrhage, have all been previously reported to mimic an inguinal hernia that suddenly becomes irreducible with or without clinical features of strangulation. We add an additional interesting presentation to this list in the form of a ruptured ectopic pregnancy, which is the first such case reported in the literature. A swelling in the groin may be much more complicated than it seems on superficial consideration and good clinical acumen is constantly required in managing such cases if a satisfactory outcome without any morbidity is to be expected.

Dieulafoy's lesion of the rectum.

Dieulafoy's lesion is an uncommon cause of gastrointestinal haemorrhage. It may present with massive and life threatening bleed and although more common in the upper gastrointestinal tract, it is being increasingly reported as affecting the lower gastrointestinal tract. Diagnosis is usually achieved during proctoscopic and endoscopic visualization. In cases where there is profuse and torrential hemorrhage, angiography may help to confirm the diagnosis. There are a few treatment options available, all of which have a varying degree of success. More commonly than not, a combination of treatment is warranted as illustrated by our case. Recurrent bleeding may occur just as in cases of Dieulafoy's lesion affecting the upper gastrointestinal tract. Even though endoscopic visualization of the lower gastrointestinal tract in the presence of profuse lower gastrointestinal haemorrhage may not be possible, this important procedure should not be omitted as the bleeding source may be lying in a low and accessible location for prompt interventional haemorrhage control.

Spontaneous haemoperitoneum secondary to a Meckel's diverticulum.

Meckel's diverticulum is a relatively common gastrointestinal entity which occasionally causes complications. Meckel's diverticulum is classically described to mimic acute appendicitis when inflamed as well as being a cause of unexplained luminal gastrointestinal bleeding. An unusual cause of spontaneous non traumatic haemoperitoneum found during surgery performed for a suspected acute appendicitis in a 22-year old female is described. The patient was found to have a significant haemoperitoneum due to a bleeding serosal vessel of a Meckel's diverticulum. The diverticulum was routinely excised. It was macroscopically and histologically devoid of inflammation. The bleeding vessel was not found to be abnormal or part of an arteriovenous malformation.

Use of telemedicine in undergraduate teaching of surgery.

Telemedicine as an undergraduate teaching method was evaluated by exposing medical students to outpatient videoconferencing. Forty clinical students on a 10-week surgical rotation participated in the study. Telemedicine sessions involved videoconferencing from the general surgical outpatient department located in a sister hospital 8 km away, using a roll-about system connected by ISDN at 384 kbit/s. A questionnaire was used to assess the quality of time spent and educational information obtained by the students. On a scale of 0-10, the students gave an overall rating of 9.7 for outpatient teaching using telemedicine. All 40 students indicated a willingness to return for similar teaching sessions. Even though the results were encouraging, an objective assessment of the knowledge gained by the students is required before the inclusion of this teaching technique in an existing medical curriculum can be recommended unequivocally.

Stercoral perforation associated with parathyroid adenoma.

We describe the case of a patient who presented with stercoral perforation of the sigmoid colon in association with hypercalcaemia caused by a parathyroid adenoma. Colonic resection was followed by successful parathyroidectomy and resulted in a satisfactory outcome. This unusual association is discussed.

Intraabdominal haemangiopericytoma associated with uncontrolled diabetes mellitus.

Haemangiopericytoma (HPC) is a rare tumour with a predilection for the central nervous system. Though previously thought to originate from the meninges and ventricular walls, HPC's are currently accepted as distinct mesenchymal neoplasms unrelated to meningiomas. Haemangiopericytomas have been previously reported to be associated with the production of insulin like growth factor II (IGF-II) and hypoglycaemia. A case of a 61-year-old poorly controlled diabetic lady with a rare presentation of an abdominal haemangiopericytoma is discussed. A laparoscopic assisted resection of the massive lobulated tumour arising from the parietal peritoneum with dense attachment to the diaphragm and the liver was performed with an uncomplicated postoperative recovery. Control of the patient's diabetes improved dramatically following surgery and the rare association of hyperglycaemia and HPC, which has not been previously described, is elaborated upon in this report.

Barium peritonitis--following barium enema of the proximal colon through a colostomy.

Perforation with extravasation of barium is a rare complication of contrast enema examination of the large bowel with a high associated mortality rate. The experience of performing a re-laparotomy in a patient previously exposed to barium peritonitis is even less common. We describe an elderly male patient with a Hartmann's procedure performed a year previously, presenting with peritonitis following barium enema evaluation of the proximal colon via an end descending colon stoma. Emergency laparotomy, segmental bowel resection and liberal peritoneal toilet resulted in a satisfactory outcome. The patient had a subsequent successful reversal of his Hartmann's procedure nine months later despite the presence of dense barium induced adhesions. This potentially preventable iatrogenic complication is discussed in this report, which is supplemented by a brief review of the English literature.

Appropriate utilisation of emergency upper gastrointestinal endoscopy in a tertiary referral centre.

A retrospective cross-sectional study was carried out in a tertiary referral centre to determine the appropriateness of usage of emergency upper gastrointestinal endoscopy (EUGIE) with reference to the guidelines set by the American Society of Gastrointestinal Endoscopy (ASGE). EUGIE was defined as early, non-elective endoscopy performed for in-patients within 48 hours of acute hospital admission. The median age of the 668 patients was 55 years (age range 12- 90), 31% of whom had a previous upper gastrointestinal endoscopy. Bleeding in the form of haematemesis, melaena or anaemia was the most common indication (40.7%) for EUGIE. Eighty one percent of the procedures were judged appropriate by the ASGE guidelines. There was a statistically significant relationship between appropriateness and significant diagnostic yield (P<0.05). Procedures performed for melaena, symptomatic anaemia and haemetemesis led to greater significant diagnostic yield (P<0.05) and there was no difference in the yield between working-hours and after-hours EUGIE.

Undergraduate surgical teaching utilizing telemedicine.

OBJECTIVES: To evaluate the concept of a new telemedicine orientated educational application by exposing junior medical students to surgical teaching via video-conferencing from the operating theatre and comparing this to the traditional method currently employed, which requires the presence of students in the operating room. To determine student satisfaction with this novel method and identify deficiencies associated with traditional surgical teaching. DESIGN: Students were connected by video-conferencing equipment 2 Mbit/s permanent virtual circuits that provided two-way picture and voice communication. Traditional tutoring involved students attending the operating theatre in set numbers. Video recordings were made during the telemedicine transmission for highlighting important factors relevant to the operative procedure. A questionnaire was used to assess the quality of time spent and information obtained by the students. SETTING: Telemedicine centre and operating theatre, St Mary's Hospital, London. SUBJECTS: Junior clinical students. RESULTS: The median score for surgical teaching utilizing video-conferencing was 9 (scale 0-10) compared to 5 for traditional operating theatre surgical teaching. All 46 (100%) subjects indicated a willingness to return for the telemedicine influenced method of tutoring compared to 65% of students exposed to the conventional method. CONCLUSIONS: Our early experience with telemedicine assisted surgical teaching indicate high acceptance and satisfaction rates by clinical students. Further studies to evaluate the objective gain in knowledge associated with this method is required prior to its implementation in any future medical curriculum.