Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas.

BACKGROUND: The treatment of rectovaginal and ileal pouch-vaginal fistulas remains a challenging problem for the colorectal surgeon. The aim of this study was to assess the short-term efficacy of the new Surgisis Biodesign rectovaginal button fistula plug in patients with such fistulas. METHODS: Between May 2008 and September 2008, patients with confirmed rectovaginal and ileal pouch-vaginal fistulas with backgrounds of inflammatory bowel disease were treated with the button fistula plug. The fistulas were assessed by magnetic resonance imaging and/or examination under anesthesia before the procedure. RESULTS: Twelve patients with a median age of 36 (range, 29-42) years underwent a total of 20 plug insertions. Five patients had confirmed rectovaginal fistulas and seven patients had ileal pouch-vaginal fistulas. At a median follow-up of 15 (interquartile range, 10-21) weeks, 7 of 12 patients (58%) had been treated successfully. Seven of the 20 plugs that were inserted (35%) were successful. This equates to the successful treatment of three of five (60%) of the rectovaginal fistulas, and four of seven (57%) of the ileal pouch-vaginal fistulas. Of the six patients who initially failed, a repeat procedure was performed of which one was successful. Two patients underwent a third repeat procedure, which was again unsuccessful in both cases. The success rate of these eight repeat plug insertions was therefore 12.5%. All plug failures were the result of dislodgement of the plug. There was no morbidity in our series. CONCLUSIONS: The new button fistula plug successfully treated 7 of 12 (58%) rectovaginal and ileal pouch-vaginal fistulas.

Needle core biopsy for the assessment of unilateral breast masses in men.

Although unilateral male breast swelling is relatively common, a histological diagnosis is infrequently obtained. From 1998 to 2003 we routinely performed needle core biopsy on all men presenting with unilateral breast swelling in whom there was diagnostic uncertainty. Of 113 patients, 93% had gynaecomastia, two patients had primary breast cancer and one had metastatic lymphoma. One patient had chronic mastitis. Gamolenic acid treatment produced a 73% response rate amongst patients presenting with pain. Core biopsy is a safe and effective method of diagnosing unilateral male breast swelling, which allows either confident reassurance or definitive treatment of those with cancer or pain.

Back to basics--cutting the cord on umbilical infections.

INTRODUCTION: Surgical site infections (SSIs) are a significant cause of postoperative morbidity with laparoscopic surgery associated with lower SSI rates. However, a departmental change in our unit to increased laparoscopic colorectal surgery resulted in increased wound infection rates at umbilical specimen extraction sites, the cause of which we attempted to elucidate. SUBJECTS AND METHODS: Prospectively collected data over an 18-month period (April 2008 to September 2009) for laparoscopic colorectal operations in a busy teaching hospital were retrospectively analysed, focusing on operation performed, whether pre-operative skin cleansing was employed, nature of specimen extraction excision, and rate of umbilical wound infection. Comparison was made with open colorectal procedures performed in the preceding year. RESULTS: In total, 275 laparoscopic colorectal operations were performed. Over the first 8 months there was a significant increase in infection rates when compared with open procedures over a similar time period (23.5% vs 8.0%; P = 0.0001). Changing practice to use pre-operative skin cleansing and an incision that skirted around, as opposed to traversing, the umbilicus reduced umbilical infection rates significantly from 23.5% to 11.6% (P = 0.01). Patients undergoing right hemicolectomy benefitted more (reduction of 30.0% to 6.9%; P = 0.04) than those undergoing anterior resection (26.8% vs 15.6%, P = 0.13). CONCLUSIONS: Umbilical incisions, when extended for specimen extraction, are particularly prone to infection following colorectal surgery but rates can be reduced by simple measures such as pre-operative umbilical cleansing and avoidance of the umbilicus in the incision, without the need for drastic and costly changes in technique or antibiotic prophylaxis.

Consenting for pelvic nerve injury in colorectal surgery: need to address age and gender bias.

INTRODUCTION: Pelvic nerve injury is a recognised complication following pelvic dissection in colorectal surgery. It can lead to urinary and sexual dysfunction in men and women, which varies from 5-40% depending on the surgery and the underlying pathology. Sexual dysfunction can manifest as erectile dysfunction in men and as dyspareunia and failure to achieve sexual arousal/orgasm in women. The aim of this study was to evaluate consent for these complications prior to surgery. PATIENTS AND METHODS: We carried out a retrospective audit on patients who had undergone elective colorectal surgery involving pelvic dissection over a 2-year period (June 2006 to June 2008) at University Hospital of North Staffordshire. We reviewed the consent forms and medical records of these patients, specifically looking for documentation of pelvic nerve injury, sexual dysfunction or erectile dysfunction prior to surgery. Only patients who had documented pelvic dissection in their operative notes were included in the audit, and those who were deemed unable to consent were excluded. RESULTS: Medical records of 118 patients were reviewed. Of this cohort, 31% were women (n = 37). Malignancy was the indication for surgery in 79% of women and 88% of men. Consent for the procedure was obtained by a consultant in 73% (n = 86) of patients and by a middle-grade surgeon in the remaining 27% (n = 32). Only two women were consented for pelvic nerve injury whilst this number was 41 for men (5% vs 51%). Patients younger than 50 years were more consistently informed of the risks (50%) compared to the over 50-year-olds (34%). Only eight patients (males 6, females 2) were consented for urinary dysfunction. CONCLUSIONS: The risk of pelvic nerve injury is not frequently stated, which is more common in women and the elderly. Overall, only 36% of patients were consented for pelvic nerve injury, while only 5% of women were consented. Is this professional discretion, or evidence that surgeons are not being assiduous enough when obtaining consent, which may leave them vulnerable to medicolegal claims? Introduction of procedure-specific consent forms would be a method to address this issue.

Interlaboratory and Intralaboratory Variability in the Analysis of Mercury in Coal.

With the passage of the 1990 Clean Air Act Amendments (CAAA), accurate determination of the concentration of mercury in coal has become an increasingly important issue. To address this issue, CONSOL R&D conducted a round robin analytical program to determine the interlaboratory and intralaboratory variability in the measurement of mercury in coal. CONSOL supplied homogeneous splits of Pittsburgh and Illinois #6 seam coals, and the NIST 1632b coal standard to eleven laboratories, twice each, over a one-year period. A twelfth laboratory analyzed the coals once. A European coal standard, certified for mercury, was analyzed at the completion of the round robin study to evaluate accuracy. The round robin participants included representatives from industry, government, and academia. The laboratories, which are experienced in mercury-in-coal analysis, used various state-of-the-art sample preparation and analysis procedures in the study. The round robin results indicate that a substantial level of variability exists in the mercury-in-coal determination. Earlier studies1 found similar results. The relative intralaboratory repeatability was 0.02 ppm and the relative interlaboratory reproducibility ranged from 0.04 to 0.05 ppm. The study showed that laboratory variability can be greatly skewed by outlier values. Fifty-six percent of the results for the European coal standard fell within a 95% confidence interval of the standard (0.138 ± 0.11 ppm). These results indicate that accuracy is not method-dependent.