Laparoscopic colectomy in a district hospital: the single surgeon can be safe.

BACKGROUND: Several outcome measures have been identified for colorectal surgery and published in the literature. This study sought to compare outcomes of high volume laparoscopic colectomy by a single surgeon in a district hospital with outcomes from tertiary referral centres. METHODS: This was a retrospective review of elective laparoscopic colectomy by a single laparoscopic general surgeon in a district hospital over a 51-month period using a prospectively maintained database. The key outcome measures studied were length of hospital stay, conversion to open, anastomotic leak, wound infection, re-admission and 30-day mortality. RESULTS: 187 elective laparoscopic colectomies were performed at the Kent and Canterbury Hospital between July 2008 and October 2012. The median patient age was 69 years (range 22-90 years). Median length of hospital stay was 4 days (range 1-48 days). Anastomotic leak occurred in 4 (2.1%) patients. Seven (3.7%) patients underwent conversion to open surgery. Re-admission occurred in 4 (2.1%) patients for small bowel obstruction (1), wound infection (1), anastomotic leak (1) and colo-vaginal fistula (1). There was one post-operative death from severe chest infection (0.5%). These results are similar to those published by tertiary referral centres. CONCLUSIONS: This study of outcomes at a district hospital shows that the outcome reported from laparoscopic colorectal surgery in tertiary referral centres is reproducible at the district hospital level by a single surgeon with a high operative volume.

Response of maternally isolated rock pigeons (Columba livia domestica) to different dietary concentrations of mannan-oligosaccharide.

Prebiotics are being used as an alternative to antibiotic growth promoters in poultry industry with a variable degree of success. This trial was conducted to investigate the effect of dietary mannan-oligosaccharide (MOS) supplementation on growth performance, selected colonic bacterial population, and immune response in maternally-isolated rock pigeons. The pigeons (n = 36) were randomly distributed in 4 treatment groups (n = 9 per group) with 3 replicates or pens (n = 3) in each group. Birds were fed either a corn/wheat-based basal diet (control group/CON) or the same diet supplemented with 0.1%, 0.2%, or 0.5% MOS for 35 d. On d 35, birds were killed to collect visceral organs, colonic contents, and serum. Colonic contents were used to enumerate selected microbiota and serum was used to detect antibody titer against the Newcastle disease virus. Cell-mediated immunity was determined by measuring the skin thickness following 2,4-dinitrochlorobenzene challenge. Results showed that supplementation did not affect the BW of birds. During wk 4, feed intake was significantly higher in the 0.2% (187.9 ± 0.86) and the 0.5% (186.4 ± 0.86) MOS-supplemented groups compared with the CON group (180.7 ± 0.86). Gizzard weights (with and without digesta) were significantly higher in the MOS 0.1% (10.67 ± 0.33 and 8.22 ± 0.26) and the MOS 0.2% (9.91 ± 0.33 and 7.94 ± 0.26) groups compared with the CON group (7.56 ± 0.33 and 6.25 ± 0.26). Small intestinal weight was significantly higher in the MOS 0.2% group (14.71 ± 0.56) compared with the CON group (9.56 ± 0.56). Lengths of small intestine (MOS 0.1% = 92.56 ± 1.69, MOS 0.2% = 90.79 ± 1.69, MOS 0.5% = 90.57 ± 1.69) in all the MOS-fed groups and large intestine in the 0.1% (3.50 ± 0.02) and the 0.5% (3.47 ± 0.02) MOS-fed groups were significantly higher than the CON group (small intestine = 77.63 ± 1.69, large intestine = 2.41 ± 0.02). Weights of heart, liver, pancreas, and large intestine remained unaffected. Feeding of MOS did not influence colonic population of Escherichia coli, Clostridia, and Bifidobacteria. Lactobacilli count was significantly higher in the 0.2% MOS-fed group (9.77 ± 0.12) compared with the CON group (9.19 ± 0.16). Mannan-oligosaccharide did not affect the immune response of the birds as antibody titer against the New Castle disease virus and the cell-mediated immunity remained similar in all the treatment groups. In conclusion, dietary MOS supplementation influenced only the colonic lactobacilli population without any apparent effects on the production performance in growing pigeons.

The Impact of High Surgical Volume on Outcomes From Laparoscopic (Totally Extra Peritoneal) Inguinal Hernia Repair.

PURPOSE: Laparoscopic hernia repair is characterised by a steep learning curve for the surgeon, and proficiency and outcomes are dependent on experience. The aim of this study was to compare laparoscopic totally extra peritoneal (TEP) inguinal hernia repair outcomes conducted by a single surgeon as experience changed over time. MATERIALS AND METHODS: Clinical records of 100 consecutive patients who underwent laparoscopic TEP inguinal hernia repair (n=113 hernias) at Kent and Canterbury Hospital by a single laparoscopic surgeon over a four-year period were reviewed for postoperative outcomes. Outcomes were compared with a previous cohort of patients undergoing TEP repair in the preceding three years. RESULTS: One patient experienced chronic postoperative pain, but there were no recurrences, wound infections, haematomas, or conversions compared to three recurrences, three conversions to open operations, one haematoma, and one episode of postoperative pain in the preceding period. CONCLUSIONS: Laparoscopic TEP inguinal hernia repair can be further improved with surgical proficiency and high surgical volumes.

Effect of folic acid supplementation on genomic DNA methylation in patients with colorectal adenoma.

BACKGROUND AND AIMS: A low dietary folate intake can cause genomic DNA hypomethylation and may increase the risk of colorectal neoplasia. The hypothesis that folic acid supplementation increases DNA methylation in leucocytes and colorectal mucosa was tested in 31 patients with histologically confirmed colorectal adenoma using a randomised, double blind, placebo controlled, parallel design. METHODS: Subjects were randomised to receive either 400 microg/day folic acid supplement (n = 15) or placebo (n = 16) for 10 weeks. Genomic DNA methylation, serum and erythrocyte folate, and plasma homocysteine concentrations were measured at baseline and post intervention. RESULTS: Folic acid supplementation increased serum and erythrocyte folate concentrations by 81% (95% confidence interval (CI) 57-104%; p<0.001 v placebo) and 57% (95% CI 40-74%; p<0.001 v placebo), respectively, and decreased plasma homocysteine concentration by 12% (95% CI 4-20%; p = 0.01 v placebo). Folic acid supplementation resulted in increases in DNA methylation of 31% (95% CI 16-47%; p = 0.05 v placebo) in leucocytes and 25% (95% CI 11-39%; p = 0.09 v placebo) in colonic mucosa. CONCLUSIONS: These results suggest that DNA hypomethylation can be reversed by physiological intakes of folic acid.

Extended thromboprophylaxis following lower limb arthroplasty: what do the clinical trials mean?

Patients undergoing major orthopaedic surgery are at high risk of thromboembolic complications. Of the available options for pharmacologic prophylaxis, the low-molecular-weight heparins (LMWHs) have been shown to be most effective in reducing the incidence of venous thromboembolic complications and are well tolerated. However, as the risk of venous thromboembolism persists for several weeks post-discharge, there is controversy regarding the ideal duration of prophylaxis. Six recent studies have examined the efficacy and safety of prolonged prophylaxis in this setting. Five of these studies have demonstrated that prolonged LMWH prophylaxis (either enoxaparin or dalteparin) for 4--5 weeks is beneficial and significantly superior to conventional prophylaxis for 7--15 days. The other study, using ardeparin, examined clinical endpoints and showed a minor trend but no significant reduction in these events. Furthermore, two of the studies -- one with enoxaparin and one with dalteparin -- also demonstrated a significant reduction in the incidence of proximal deep vein thrombosis. Analysis of all clinical events from the five studies that have published that information shows a halving or 51% reduction in favour of prolonged prophylaxis. On the basis of current evidence, prolonged thromboprophylaxis with LMWH for up to 35 days after major orthopaedic surgery is recommended.