Is Clostridium difficile infection a particular problem after reversal of ileostomy?

AIM: Clostridium difficile infection (CDI) is a cause of morbidity and mortality in hospitals. Various independent risk factors have been identified, including age and antibiotic exposure. This study attempted to determine whether surgery and associated antibiotic use influence the development of CDI. METHOD: A retrospective review of all patients with a diagnosis of CDI diagnosed during admission to a colorectal unit was conducted over a 20-month period. Patient records were cross-referenced with a microbiology database to identify previous episodes of infection and cases of recurrence. RESULTS: There were 38 CDI episodes in 29 patients, including nine with recurrence. In 33, the use of antibiotics prior to the onset of CDI was documented, but in 14 (37%) patients this was limited to perioperative prophylaxis. The incidence of CDI after various procedures was as follows: ileostomy closure (4.2%), right hemicolectomy (2.1%) and anterior resection (1%). CONCLUSION: Ileostomy closure may carry a higher risk of CDI.

Randomized clinical trial of the influence of local subcutaneous infiltration vs subcutaneous and deep infiltration of local anaesthetic on pain after appendicectomy.

INTRODUCTION: Local anaesthesia is commonly used to provide pain relief after surgery. The aim of this randomized, blinded prospective trial was to evaluate whether local subcutaneous and deep infiltration of local anaesthetic provides better postoperative pain control than subcutaneous infiltration alone. METHOD: Eighty-four patients undergoing open appendicectomy for presumed acute appendicitis were randomly assigned into two groups. Group A received local infiltration of the skin prior to incision with bupivacaine whilst group B received half the bupivacaine infiltrated into the skin and the other half deep-to-external oblique to create a local nerve field blockade. Postoperative pain was assessed, on a scale of 1 to 10, at 1, 4, 8 and 24 h postextubation. RESULTS: At time intervals of 1, 4 and 8 h, there was no significant difference in pain score between group A and group B. At 24 h group B had significantly lower pain scores than group A (2.3 vs 3.4, P = 0.016). CONCLUSION: Both methods of administration of local anaesthetic produced consistently low pain scores in the first 24 h after appendicectomy. There may be additional benefit in a local nerve field blockade in combination with local anaesthetic skin infiltration.

Complications during the waiting period for carotid endarterectomy.

We conducted a retrospective analysis to determine the number of cerebrovascular complications occurring in the period between initial presentation and operation in patients undergoing carotid endarterectomy. The notes of patients undergoing carotid endarterectomy during a 2-year period were used to quantify delays between initial presentation and surgery and complications occurring in this time period. A group of 49 patients was analyzed. The median time period between referral following initial cerebrovascular event and carotid endarterectomy was 62 days. During this time period 12 (24.5%) ischemic complications occurred including six transient ischemic attacks. Delays occurred at a variety of levels but included a median of 36 days before patients seen in the stroke clinic were referred to a surgeon and a median of 23 days before operation once patients had seen a surgeon. Significant delays still exist between initial presentation and carotid endarterectomy and can lead to further ischemic episodes prior to surgery.

22-year longitudinal study of repetitive colonoscopy in patients with a family history of colorectal cancer.

INTRODUCTION: We report the outcomes of a long-term surveillance programme for individuals with a family history of colorectal cancer. METHODS: The details of patients undergoing a colonoscopy having been referred on the basis of family history of colorectal cancer were entered prospectively into a database. Further colonoscopy was arranged on the basis of the findings. The outcomes assessed included incidence of cancer and adenoma identification at initial and subsequent colonoscopy. RESULTS: The records of 2,293 patients (917 men; median patient age: 51 years) were entered over 22 years, giving data on 3,982 colonoscopies. Eight adverse events (0.2%) were recorded. Twenty-seven cancers were found at first colonoscopy and thirteen developed during the follow-up period. There were significantly more cancers identified in those with more than one first-degree relative with cancer than in other groups (p=0.01). The number of adenomas identified at subsequent surveillance colonoscopies remained constant with between 9.3% and 12.0% of patients having adenomas that were removed. Two-thirds (68%) of patients with cancer and three-quarters (77%) with adenomas fell outside the British Society of Gastroenterology (BSG) 2006 guidelines. CONCLUSIONS: Repeated colonoscopy continues to yield significant pathology including new cancers. These continue to occur despite removal of adenomas at prior colonoscopies. The majority of patients with cancers and adenomas fell outside the BSG 2006 guidelines; more would have fallen outside the 2010 guidelines.