Direct Access Minor Surgery service--patient satisfaction and effectiveness.

INTRODUCTION: Waiting lists for surgical out-patients and elective operations are a major concern of the National Health Service. A Direct Access Minor Surgery programme in an ambulatory minor theatre area has been introduced to expedite patient treatment. The response of patients to this service has been assessed. PATIENTS AND METHODS: A postal questionnaire was offered to all patients attending for the Direct Access Minor Surgery over a period of 20 months (January 2002 to August 2003). Patients were asked about direct attendance for surgery without a prior out-patient appointment, about waiting time before operation on the day of surgery and the adequacy of pre-operative information. Overall satisfaction was assessed using a scoring system. The incidence of inappropriate referrals was analysed. The influence of the service on waiting lists and resources was assessed. RESULTS: A total of 221 patients were operated on, 257 lesions being excised. Response rate to the postal questionnaire was 55%. Of respondents, 75% thought that it was appropriate to attend the hospital directly without an out-patient clinic appointment. To 83% the waiting time was acceptable. Of patients, 90% were happy with the pre-operative information. Overall, 91% of respondents were very satisfied with the service. Inappropriate referrals were 4%. The new service reduced waiting time for minor surgery from 53 to 10 weeks. It also released approximately 140 new out-patient slots per annum. CONCLUSION: Direct Access Minor Surgery is a safe and favoured service with high patient satisfaction.

Bile reflux and intestinal metaplasia in gastric mucosa.

AIM: To determine associations between enterogastric bile reflux and gastric mucosal pathology. METHOD: A retrospective study using fasting gastric juice bile acid measurements and antral or prestomal biopsy specimens from 350 patients, 66 of whom had previously undergone surgery that either bypassed or disrupted the pyloric sphincter. RESULTS: Bile reflux was positively associated with reactive gastritis and negatively with Helicobacter pylori density. After stratification for previous surgery, age, and H pylori status, the histological feature most strongly associated with bile reflux was intestinal metaplasia, including all its subtypes. The prevalence of intestinal metaplasia was greatest in patients with both H pylori infection and high bile acid concentrations. Bile reflux was also positively associated with the severity of glandular atrophy, chronic inflammation, lamina propria oedema and foveolar hyperplasia. CONCLUSIONS: Bile reflux is a cause of reactive gastritis. It modifies the features of H pylori associated chronic gastritis. The changes are not confined to patients who have had surgery to their stomachs. The positive associations with atrophy and intestinal metaplasia have implications for models of gastric carcinogenesis.

A multicentre study to compare piperacillin with the combination of netilmicin and metronidazole for prophylaxis in elective colorectal surgery undertaken in district general hospitals.

We have conducted a multicentre randomized study to compare piperacillin with the combination of netilmicin and metronidazole in patients undergoing elective colorectal surgery. There was no significant difference in the incidence of operation-related infection, chest or urinary tract infection. Major life-threatening sepsis occurred in 6% and the overall incidence of operation-related infection was 24%. Organisms which normally inhabit the bowel lumen were cultured from most of the postoperative infections; however, Staphylococcus aureus was isolated as a causative organism in nine patients in the piperacillin group compared with none in the netilmicin and metronidazole group. We are concerned at the high incidence of infection in both groups, and we believe that other factors in addition to prophylactic antibiotics need to be evaluated if the incidence of infection is to be reduced further.

A double stapled technique for oesophago-enteric anastomosis.

AIM: Leakage from oesophageal anastomosis is associated with substantial morbidity and mortality. This study presented a novel, safe and effective double stapled technique for oesophago-enteric anastomosis. METHODS: The data were obtained prospectively from hospital held clinical database. Thirty nine patients (26 males, 13 females) underwent upper-gastrointestinal resection between 1996 and 2000 for carcinoma (n = 36), gastric lymphoma (n = 1), and benign pathology (n = 2). Double stapled oesophago-enteric anastomosis was performed in all cases. RESULTS: No anastomotic leak was reported. In cases of malignancy, the resected margins were free of neoplasm. Three deaths occurred, which were not related to anastomotic complications. CONCLUSION: Even though the reported study is an uncontrolled one, the technique described is reliable, and effective for oesophago-enteric anastomosis.

Early return to work following highly selective vagotomy.

In the Royal Navy, after surgery, the time that servicemen spend away from work and the level of duty to which they return are decisions made by the surgeon, not the general practitioner. In a prospective study, we have thus been able to assess the acceptability of return to full duty at decreasing intervals after highly selective vagotomy (HSV). Seventy-eight servicemen who underwent HSV for duodenal ulcer were studied in three periods, 1978-1980, 1981-1982, 1983-1986, each with a shorter interval to return to duty. There were no differences in the rates of ulcer recurrence, incisional hernia, or ability to perform full duties. After HSV the mean time to return to full duties for each group was 29.3, 16.4, and 4.2 weeks, respectively. Every patient returned to full duties at 28 days was able to perform any assigned task whether at sea or ashore.

Primary Casualty Reception Ship: the hospital within--Operation Granby.

As the build-up of Operation Granby forces developed in the Gulf, casualty estimates indicated the need for a 100-bed hospital facility to care for the possible maritime casualties. RFA Argus, the Air Training Ship, was identified as the potential Primary Casualty Reception Ship (PCRS) and at the end of September 1990 plans were drawn up to convert the forward hangar into a two-storey 100-bed hospital in collective protection (COLPRO). In the three weeks prior to deployment, the hospital was designed, built, equipped and staffed. Argus arrived in the Gulf in mid-November as the PCRS with, all in COLPRO, a 10-bed intensive care unit (ICU), a 14-bed high dependency unit (HDU), a 76-bed low dependency unit (LDU) plus four operating tables in two theatres with full support services. The hospital was staffed by a medical team of 136 personnel and supported by the Air department with four casualty evacuation helicopters, an RN Party and the staff of the RFA. One hundred and five patients were treated of which 78 were returned to duty. Argu as PCRS spent longer in the northern Persian Gulf than any other ship, UK or US.

Operating at sea in an aircraft carrier.

The policy of the Medical Officers serving in HMS Ark Royal between January 1988 and June 1989 with regard to surgery and anaesthesia at sea is described. The skills and equipment available, techniques used, operations performed and complications that resulted are outlined. The advantages and disadvantages of an active operating policy are discussed and the postulate ventured that in order to achieve maximum efficiency within the medical department of an aircraft carrier such a policy is justified. Finally, in the light of present day litigious trends, the question of the propriety of the policy is posed.

Oesophageal leiomyoma--a rare cause of reflux oesophagitis.

Reflux oesophagitis is a common condition encompassing a spectrum of symptoms. We report an apparently novel cause of this condition, and highlight possible symptomatology that may be suggestive in its pre-operative diagnosis.

von Recklinghausen's disease of nerves: a modern day social response.

We describe a patient with von Recklinghausen's Disease of Nerves whose appearance provoked an emotive reaction in the close community of an RN ship akin to that reported in the case of Sir Frederick Treves' "Elephant Man". The RN divisional system provided a valuable contribution to the resolution of the problems created.

The boat people of Vietnam. Rescue on the South China Sea.

Poor economic conditions in Vietnam have encouraged large numbers of people seeking a better life in the West to join the flow of political refugees leaving the country as "boat people". We report the events surrounding one such group of people who were rescued from the South China Sea by the Outback 88 Task Group.