The Pathophysiology, Presentation and Management of Ischaemic Colitis: A Systematic Review.

There are currently no guidelines on the long-term management of patients after an episode of acute ischaemic colitis. Our aim was to review the literature on the pattern of presentation and the pathophysiology of this condition and to understand the current status of the acute and long-term management of ischaemic colitis. Furthermore, we aim to provide recommendations for the clinicians in regard to the acute and long-term management of ischaemic colitis. A review of the English literature over the last 15 years was performed using Embase and Medline. Search terms were ischaemic OR ischemic, colitis OR colon. Two reviewers screened the papers against pre-determined eligibility criteria. A senior consultant surgeon performed a final overview. Three hundred sixty-eight papers were identified on the initial search; 318 were irrelevant and 17 were conference abstracts; both were excluded. Thirty-three full articles were assessed for suitability; nine were further excluded. Twenty-four articles were included in the final analysis and cross-referenced against those listed in the systematic reviews. There is a large clinical heterogeneity in inclusion criteria (histological, radiological, endoscopic, surgical specimen). Twelve out of 24 articles included patients only based on histological diagnosis. The definition of right and left (or nonright) ischaemic colitis was variable based on whether hepatic or splenic flexure was used as the cut-off point. Five retrospective case series highlighted that patients with isolated right-sided ischaemic colitis had a worse prognosis than those with left-sided colitis (higher mortality, need for surgery, length of hospital stay). The overall recurrence was 9%. There is a need for a higher-level evidence to guide clinicians on the long-term management of patients following an episode of acute colonic ischaemia. Further evidence is required to determine whether right colonic ischaemia should be managed differently from left.

Safe removal of long-term venous catheters in the neck.

AIMS: Tunnelled venous catheters are a well-established method of long-term venous access for total parental nutrition, chemotherapy and antimicrobial treatment. Removal of these catheters is a simple procedure; however, there are some significant risks. METHODS: We report a case in which a serious complication occurred. A simple technique for the safe removal of long-term venous catheters is described. CONCLUSION: A direct surgical removal is now generally favoured for safe line removal. However, this still carries the same complications and care must be taken in the technique.

Obstructive perianal lesion in a 75-year-old man.

A 75-year-old man presented with a fungating peri-anal mass which appeared malignant at presentation and required a defunctioning colostomy due to abdominal distension. Multiple biopsies were negative for malignancy and CT/MRI scans showed no malignant mass. A provisional diagnosis of prolapsed haemorrhoids was made and the mass was treated with sugar and charcoal dressings. There was a dramatic resolution of the mass with this treatment and the patient was discharged 1 month post-admission. The patient then underwent an elective haemorrhoidectomy by which time the mass had decreased to a perianal skin tag. The only clues in this case were the acute presentation of the mass, the fact that the mass had appeared post-defecation and that the patient had been diagnosed with haemorrhoids 2 years previously on colonoscopy. This case highlights the importance of evaluating all investigations and considering all differential diagnoses before embarking on definitive management.

Vacuum-assisted closure of postoperative abdominal wounds: a prospective study.

BACKGROUND: We aimed to study outcome in patients with an open abdomen in whom the abdominal vacuum-assisted closure system (V.A.C.((R)) Therapy()) was used to provide temporary cover and achieve wound closure. METHODS: All patients in whom V.A.C. Therapy was used to manage laparotomy wounds between February 2006 and May 2007 at a University Teaching Hospital were followed up prospectively until successful completion or stoppage of V.A.C. Therapy. RESULTS: Of the 51 consecutive patients (33 male), V.A.C. Therapy was used to manage a laparostomy in 10 patients and abdominal wound dehiscence in 41. Median (IQR) duration of V.A.C. Therapy was 17 (7-26) days. Wound healing was achieved in 31 (61%) patients, four of whom had additional surgery to assist wound closure. The rest healed by secondary intention. Treatment was withdrawn due to therapy-related complications in nine patients and due to medical or logistical reasons in seven. Four patients died while on therapy. While most V.A.C. Therapy-related problems were minor, two patients developed enteric fistulae that necessitated surgical repair. At a median (IQR) follow-up of 8 (4-13) months, 18 patients had stable cutaneous coverage with no incisional hernia, 12 developed an incisional hernia, 9 were lost to follow-up, and 12 died. CONCLUSIONS: V.A.C. Therapy is a useful adjunct in the management of the open abdomen and should be considered in the treatment of this problem. Restoration of cutaneous and fascial integrity of the abdominal wall, the risk of fistulisation, and the cost-effectiveness of this therapy require further evaluation.

Sensory abnormalities and bruising after long saphenous vein stripping: impact on short-term quality of life.

BACKGROUND: We assessed the impact of postoperative sensory abnormalities and bruising after long saphenous vein (LSV) stripping on short-term quality of life (QOL). METHODS: Seventy patients with LSV incompetence were recruited before surgery. Surgery involved saphenofemoral disconnection, stripping of the LSV in the thigh, and multiple stab avulsions in all patients. Sensory abnormalities (subjective and objective) and bruising were recorded at two follow-up visits (mean, 8 and 47 days). The bruised area was traced manually, and the surface area was estimated by placing the tracing on a square chart. A QOL assessment was performed before surgery and repeated during the second visit by using the Aberdeen Varicose Veins Questionnaire. Minitab version 13.32 was used for statistical analysis. RESULTS: Eight patients either did not complete follow-up or were excluded from the final analysis. Final analysis was performed on 63 limbs in 62 patients (27 men and 35 women; age, 19-75 years). The overall incidence of postoperative sensory abnormality was 40% (25/63 limbs). This included numbness or decreased sensation in 36.5% (23/63), paresthesia in 8% (5/63), and dysesthesia in 1.6% (1/63). Irrespective of the presence of sensory abnormalities, QOL scores improved after surgery (mean change in QOL score, -7.58 and -7.52; SE, 1.1 and 1.3 in those with and without sensory abnormalities, respectively). There was no significant difference either in the degree of improvement in the QOL score (P = .972; t test) or in the proportion of patients with an improved score (P = .69; Fisher exact test) between the groups with and without sensory abnormalities. Postoperative bruising at first follow-up ranged from 28 to 1419 cm(2) (mean, 500.7 cm(2); median, 438 cm(2)). Both groups--those who bruised less than the median value (438 cm(2)) and those who bruised more than the median value--showed improved postoperative QOL scores (mean change in QOL score, -7.64 and -7.46; SE, 1.3 and 1.3, respectively). There was no significant difference either in the degree of improvement in the QOL score (P = .924; t test) or in the proportion of patients with an improved score (P = .422; Fisher exact test). All patients with persistent bruising at the second follow-up (26%) also showed an improvement in the QOL score (mean change in QOL score, -10.29). CONCLUSIONS: Conventional surgery for varicose veins with stripping of the LSV is associated with significant morbidity of sensory abnormalities and bruising. However, this does not adversely affect postoperative improvement in short-term QOL.