Anemia to Median Nerve Palsy.

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

Predicting length of stay for acute medical admissions in New Zealand: the MALICE score.

Predicting length of stay (LoS) in hospital can help guide patient placement, facilitate rapid discharge and aid identification of patients at risk of prolonged stay, in whom early multidisciplinary intervention is warranted. We aimed to pilot the applicability of a modified decision aid (MALICE score) for predicting LoS for acute medical admissions at a New Zealand hospital. A prospective pilot study of 220 acute general medical admissions was performed. Clinical records were reviewed and MALICE scores were calculated for each patient and compared with LoS data using the Kruskal-Wallis H test. A statistically significant increase in LoS was seen with rising MALICE scores (H value 26.85, P < 0.001). MALICE scoring could be employed to guide patient placement and identify patients at risk of prolonged stays, though further study of bedside feasibility and applicability is required.

Nontraumatic Emergency Laparotomy: Surgical Principles Similar to Trauma Need to Be Adopted?

OBJECTIVES: In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival. METHODS: All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis. RESULTS: In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality. CONCLUSIONS: The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia.

Colonic Perforation: A Medical Complication.

Hypothyroidism is a common comorbidity that on acute presentation is often overlooked. It can be an easily managed condition; however non-compliance can have severe consequences. In the presented case it was requirement for emergency surgery that resulted in stoma formation. This case is a first example of the need to include patient's decision making process with regards to medication adherence in the setting of chronic disease.

Avoiding emergency stoma surgery with the use of sugar.

George Theofanis, Mahmud Saedon, Soo Hua Kho, Francesk Mulita, Stylianos Germanos and Edmund Leung discuss the use of sugar as an aid to reducing a stomal prolapse.

Preliminary results of sacral transcutaneous electrical nerve stimulation for fecal incontinence.

BACKGROUND: Fecal incontinence is a common debilitating condition. OBJECTIVE: The aim of this study is to investigate the feasibility of sacral transcutaneous electrical nerve stimulation as an alternative treatment modality for fecal incontinence. DESIGN: All consecutive patients who presented with fecal incontinence to the senior author's clinic were prospectively recruited between June 2009 and September 2010. The severity of their fecal incontinence was assessed by the Wexner and Vaizey scores and anal physiology. MAIN OUTCOME MEASURES: Any improvement following a period of sacral transcutaneous electrical nerve stimulation treatment was determined by repeating the scores. In addition, patient satisfaction with the procedure was assessed by using a patient impression score. RESULTS: Twenty female patients with a median age of 57.5 years (range, 30-86) were evaluated. The median follow-up was 10 months (range, 5-12 months). Two patients did not record a change in their Vaizey score. The overall mean Wexner score was 7.9 ± 4.2 before in comparison with 4.0 ± 3.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 2.2-5.7, SE = 0.832). The overall mean Vaizey score was 12.7 ± 5.7 before in comparison with 5.8 ± 5.6 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 4.5-9.4, SE = 1.162). The pretreatment patient impression score was set at a mean of 1 ± 0 in comparison with 2.8 ± 1.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 1.2-2.3, SE = 0.25). CONCLUSION: The preliminary results suggest sacral transcutaneous electrical nerve stimulation is a promising noninvasive alternative to existing modalities in the treatment of idiopathic fecal incontinence.

The Two-Week Referral System for colorectal cancer--not fit for purpose.

PURPOSE: The UK government target expects all suspected colorectal cancer (CRC) patients to be seen within the Two-Week Referral (TWR) system made by general practitioners. These guidelines originally derived from only level 5 evidence. However, this has significant impact on the workload for colorectal surgeons. The aim of the study is to investigate the effectiveness of this colorectal service and whether the referral criteria are predictive of CRC. METHODS: A retrospective study of all patients referred under the TWR guidance in 2010 was assessed. The first 573 TWRs were piloted for analysis. Clinical information from each patient was collected regarding TWR criteria and additional colorectal symptoms or risk factors. Multiple regression analysis was performed to determine which symptoms independently correlated with CRC. RESULTS: One hundred twenty-six CRCs were diagnosed via all methods of referral in 2010. There were 940 patients referred under the TWR guidelines in that year, when 50 CRC patients were identified. Amongst the 573 patients, 32 CRCs were diagnosed. Multiple regression analysis revealed tenesmus to be independently associated with CRC (p = 0.003, Pearson's r = 0.09185). None of the individual TWR criteria confidently predicted CRC. CONCLUSION: Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.

A further look into obtaining informed consent for medical students.

Nil.

Looking beyond the surface: Muir Torre syndrome.

Muir-Torre Syndrome (MTS) is associated with multiple visceral malignancies. Initial presentation may be a benign skin tumor mimicking a sebaceous cyst. This case report highlights the importance of early diagnosis, genetic testing, and multidisciplinary screening. A 67-year-old man was diagnosed with MTS following excision of a skin lesion (sebaceoma). He was declined both screening colonoscopy and genetic testing. Subsequently, advanced colon cancer was found following presentation with iron deficiency anemia, which ultimately led to palliation despite successful surgery. MTS can present insidiously with skin lesions clinically diagnosed as sebaceous cysts. Once MTS is suspected on histology, genetic testing and screening for MTS-related cancers is warranted. Better understanding of the genetic variants for MTS can aid in earlier diagnosis thus not dismissing the need for screening for MTS-related cancers.

Risk-adjusted scoring systems can predict surgeons' performance in colorectal surgery.

INTRODUCTION: the physiological & Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) was derived from a heterogeneous general population and has been used successfully as an audit tool to provide risk-adjusted operative mortality rate. The aim of this study was to investigate whether risk-adjusted scoring systems can accurately predict outcomes of colorectal operations done by colorectal and non-colorectal surgeons. METHOD: the study was conducted prospectively on 899 consecutive patients who underwent major elective and emergency colorectal procedures over three years between 2002 and 2004 at University Hospital Coventry and Warwickshire. The outcome parameter was defined as 30-day mortality. The observed mortality was then compared to POSSUM-predicted mortality. Hosmer-Lemeshow and Fisher's Exact test were used to assess statistical significance in outcome between non- and coloproctologists. RESULTS: CR-POSSUM was the most accurate predictive model for outcomes of major colorectal operations between surgeons. The overall mortality rate amongst coloproctologists was 7% (5% elective & 13% emergency), whereas the overall mortality was 17% (3% elective & 21% emergency) in non-coloproctologists. CONCLUSION: CR-POSSUM was the better prediction model than POSSUM. Coloproctologists delivered a significantly lower overall mortality, but not in the emergency setting. However, given the few number of elective colorectal resections performed by non-coloproctologists, more cases are required to permit meaningful comparison for the outcomes of major colorectal operations among different surgeons.

Intraoperative assessment of sentinel node using imprint cytology.

BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary sampling as the axillary staging procedure of choice in patients with breast cancer. Accurate intraoperative evaluation of the SLN would allow axillary lymph node clearance to be performed during the initial operation when the SLN is positive for metastatic disease. The aim of the present study was to assess the accuracy of intraoperative imprint cytology (IC) of the SLN in two different institutions in the United Kingdom. METHODS: All breast cancer patients who underwent a SLN biopsy using a standard protocol in two hospital breast units were included. The SLN was sent fresh to the pathology laboratory, where it was immediately processed and examined by a cytopathologist using IC. The intraoperative IC results were compared with the final histopathological results. No therapeutic decisions were made based on the results of IC in this study. RESULTS: A total of 166 patients were included, with 47 positive and 119 negative cases on final histology. Of the 47 patients who were positive on final histology, there were 29 positive and 18 negative cases on IC (sensitivity = 61.7%). All 119 patients who were negative on final histology were negative on IC (specificity, 100%). The negative and positive predictive value of the final histology was 86.9% and 100%, respectively. The accuracy of IC was 89.2%. CONCLUSIONS: The results from these two breast units are comparable with findings reported in the published literature, confirming that IC can be used to assess SLN biopsy intraoperatively. No unnecessary axillary node clearance would have been carried out based on the results of IC.

Bilo-enteric fistula (BEF) at laparoscopic cholecystectomy: review of ten year's experience.

INTRODUCTION: BEF is a rare complication of gallstone disease with reported incidence of up to 4.8%. Most are diagnosed intra-operatively and often requires conversion to open surgery. This review assesses the feasibility of laparoscopic management of BEF found at the time of laparoscopic cholecystectomy over ten-year period. METHOD: All patients undergoing elective laparoscopic cholecystectomy by a single surgeon (PK) between 1996 and 2006 were prospectively entered in a database and analysed. RESULTS: Out of 824 laparoscopic cholecystectomy, ten cases of BEF were identified at operation (1.2%, age 14-88 years, median=62). These were cholecysto-duodenal (7), cholecysto-colonic (1), cholecysto-choledocho-duodenal (1) and choledocho-duodenal (1). Two out of ten were converted to open surgery (20%) compared to overall conversion rate of 2.8% (23/824). Eight cases were successfully completed laparoscopically; endostapler was used in six patients to transect the fistula and two patients had the defect repaired by intra-corporeal sutures. No major complications were seen. One patient had a prolonged hospital stay for social reason. CONCLUSION: BEF is often detected intra-operatively and most can be managed laparoscopically successfully. Endostapling avoids peritoneal contamination and reduces operative time.

Splenic rupture following routine colonoscopy.

Splenic rupture is a life-threatening condition characterized by internal hemorrhage, often difficult to diagnose. Colonoscopy is a gold standard routine diagnostic test to investigate patients with gastrointestinal symptoms as well as to those on the screening program for colorectal cancer. Splenic injury is seldomly discussed during consent for colonoscopy, as opposed to colonic perforation, as its prevalence accounts for less than 0.1%. A 66-year-old Caucasian woman with no history of collagen disorder was electively admitted for routine colonoscopy for surveillance of adenoma. She was admitted following the procedure for re-dosing of warfarin, which was stopped prior to the colonoscopy. The patient was found collapsed on the ward the following day with clinical shock and anemia. Computed tomography demonstrated grade 4 splenic rupture. Immediate blood transfusion and splenectomy was required. Splenic rupture following routine colonoscopy is extremely rare. Awareness of it on this occasion saved the patient's life. Despite it being a rare association, the seriousness warrants inclusion in all information leaflets concerning colonoscopy and during its consent.

Leukaemia-in-ano.

Fistula-in-ano is a very common surgical condition, caused by anal cryptoglandular inflammation. Most cases are idiopathic. Other causes such as Crohn's disease, trauma and malignancy are well known. Management of fistula-in-ano is largely surgical, especially if the patient is symptomatic. The goal of surgical therapy is sepsis drainage, delineate anatomy and eradicate the fistula while preserving faecal continence. Establishing the aetiology is also crucial as often a combination of specialist medical therapy is required, for example, in Crohn's disease. We report an extremely unusual case of fistula-in-ano on an elderly man with chronic lymphocytic leukaemia (CLL). Histology from the fistula track demonstrated CLL infiltration. This case, not previously reported on PubMed search, illustrates a good example of joint specialist medical (a haematologist) and surgical effort in successfully treating this symptomatic fistula-in-ano.

Improving prescribing of extended prophylaxis for venous thromboembolism at discharge in patients who underwent surgery for colorectal cancer.

AIMS/BACKGROUND: Prophylaxis at discharge is important in mitigating venous thromboembolism events from colorectal cancer and major abdominopelvic surgery, both of which are risk factors for venous thromboembolism. Foundation doctors frequently rotate between departments, and so rely on departmental induction and/or handing down of knowledge to prescribe extended venous thromboembolism prophylaxis upon discharge. METHODS: A retrospective audit of all patients who underwent surgery for colorectal cancer at The County Hospital, Hereford, between 1 August 2018 and 31 August 2019, was undertaken to assess departmental compliance with guidance from the National Institute for Health and Care Excellence. RESULTS: A total of 181 patients underwent elective surgery and 29 patients had emergency surgery. The initial audit revealed a cyclical 4-monthly decline that coincided with foundation doctors' rotations. Six multidisciplinary interventions were implemented. Reaudit demonstrated 100% compliance with prescribing of extended venous thromboembolism prophylaxis at discharge. No venous thromboembolism events 30 days post operation were noted. CONCLUSIONS: A multidisciplinary approach involving educating health professionals about the importance of extended venous thromboembolis prophylaxis in patients who have undergone surgery for colorectal cancer can be effective in improving compliance with prescribing practices at discharge.

Predicting post-operative mortality in patients undergoing colorectal surgery using P-POSSUM and CR-POSSUM scores: a prospective study.

INTRODUCTION: POSSUM and its variants Portsmouth POSSUM (P-POSSUM) and Colorectal POSSUM (CR-POSSUM) equations were derived from a heterogeneous general surgical population, which have been used successfully to provide risk-adjusted operative mortality rates. CR-POSSUM utilises fewer parameters, allowing ease of use. The aim of this study was to predict the mortality outcome in colorectal surgery using these scoring systems compared to the observed mortality and to devise a new scoring system with improved accuracy. METHODS: The study was conducted prospectively on all consecutive patients requiring elective and emergency colorectal surgery between April 2002 and May 2005. The outcome parameter was defined as 30-day mortality. The observed mortality was compared with predicted mortality by the scoring systems. Hosmer and Lemeshow test was used to assess statistical accuracy of POSSUM. RESULTS: Eight hundred ninety-nine patients underwent colorectal surgery during the study period. There were 619 elective and 281 emergency patients. Observed 30-day mortality rate was 9%, compared with predicted mortality rate of 13.5% with POSSUM, 5% with P-POSSUM and 9.5% with CR-POSSUM. CONCLUSION: POSSUM's mortality rate was overestimated, while P-POSSUM's mortality rate was underestimated. CR-POSSUM, the simplest system of all three, most accurately predicted mortality in our unit.

Pus swabs in incision and drainage of perianal abscesses: what is the point?

BACKGROUND: The clinical effectiveness of pus swabs for microbiological analysis during incision and drainage of perianal abscess is controversial. Its cost implication is often overlooked. The present study aimed to determine if submission of pus swabs can be avoided without a negative effect on outcome. METHODS: All consecutive cases of incision and drainage of perianal abscess between January 2004 and 2008 were retrospectively reviewed. Patient demographics, microbiological results, and clinical outcome with a follow-up of 6 months were assessed. RESULTS: A review of patient records revealed 235 cases (59 F:176 M; age range: 6-99 years; median: 37 years). In 38 cases no swabs were taken; in 28 cases (12%), 106 cases (45%), and 16 cases (7%) swabs contained skin flora organisms, coliform/Bacteroides, and sterile, respectively. Within 6 months follow-up, 185 of the abscesses had healed, leaving 39 cases of fistula (25 cases had setons remained in situ for their fistulas at 6 months follow-up) and 11 patients were lost from follow-up. Fistulas were not associated with coliform/Bacteroides found on microbiological analysis (P > 0.05). In only 4 cases (1.7%) were the swab results mentioned in follow-up reports. CONCLUSIONS: Surgeons tend not to review microbiological results at patient follow-up. Furthermore, the preliminary findings suggest that microbiological results have no correlation with presence of fistulas or prognosis. Randomized controlled trials are warranted to assess whether abandoning submission of pus swabs will affect clinical effectiveness of treatment in patients with perianal abscess.

Buried coin in the gastric mucosa.

A 29-year-old man presented to the Accident and Emergency department with abdominal cramping following ingestion of a 50 p coin 2½ weeks prior to presentation. He had not observed it pass in his stools. An abdominal radiograph confirmed the presence of the 50 p coin in his stomach. Subsequently, he had an oesophagogastroduodenoscopy (OGD) performed with a failure to visualise the coin. 1½ weeks later, he returned to the department as he was still unable to observe its passing in his stools. A repeated abdominal radiograph and a CT of the abdomen and pelvis revealed that the coin was still in his stomach. A second OGD was performed once again with a failure to visualise the coin. It appeared that the coin had migrated into his gastric mucosa.