TEMS: results of a specialist centre.

INTRODUCTION: Transanal endoscopic microsurgery (TEMS) is becoming more widespread due to the increasing body of evidence to support its role. Previous published data has reported recurrence rates in excess of 10% for benign polyps after TEMS. METHODS: Bradford Royal Infirmary is a tertiary referral centre for TEMS and early rectal cancer in the UK. Data for all TEMS operations were entered into a prospective database over a 7-year period. Demographic data, complications and recurrence rates were recorded. Both benign adenomas and malignant lesions were included. RESULTS: A total of 164 patients (65% male), with a mean age of 68 years were included; 114 (70%) of the lesions resected were benign adenomas, and 50 (30%) were malignant lesions. Median polyp size was 4 (range 0.6-14.5) cm. Mean length of operation was 55 (range 10-120) min. There were no recurrences in any patients with a benign adenoma resected; two patients with malignant lesions developed recurrences. Three intra-operative complications were recorded, two rectal perforations (repaired primarily, one requiring defunctioning stoma), and a further patient suffered a blood loss of >300 ml requiring transfusion. Six patients developed strictures requiring dilation either endoscopically or under anaesthetic in the post-operative period. CONCLUSIONS: We have demonstrated that TEMS procedures performed in a specialist centre provide low rates of both recurrence and complication. Within a specialist centre, TEMS surgery should be offered to all patients for rectal lesions, both benign and malignant, that are amenable to TEMS.

Suspected appendicitis in pregnancy.

AIM: Acute appendicitis is one of the most common acute surgical presentations. However investigation and management is sometimes confounded in a pregnant patient. Appendicitis in pregnancy is often managed jointly by both the surgical and obstetric teams, which can lead to discrepant pathways, which may be detrimental to the patient. This review sets out to identify the normal physiological changes of pregnancy that pose diagnostic and therapeutic difficulties to the clinician, assess the more common differential diagnoses and review the current evidence to assist achieving a swift diagnosis and appropriate treatment. METHODS: A literature review of the investigation and management of suspected appendicitis in pregnancy was undertaken. Guidelines by the relevant surgical, obstetric and radiological societies were also reviewed. RESULTS: There remains no consensus on the best diagnostic pathway for appendicitis in pregnancy; which is unsurprising given that appendicitis in non-pregnant patients can yield diagnostic conundrums. However this review identifies a role for MRI scanning as a useful adjunct in these patients. The increasing role of laparoscopy in these patients is also becoming more apparent. CONCLUSION: Appendicitis in pregnancy remains a complex problem necessitating a close working relationship between various specialties to achieve the best outcome for mother and fetus.

Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis.

INTRODUCTION: Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. METHODS: A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. RESULTS: Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. CONCLUSIONS: Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.