Short notice cancellations - an insight into Irish surgical waiting lists.

BACKGROUND: The reasons underlying prolonged waiting lists for surgery in Ireland are multifactorial. Patient-related factors including non-attendances contribute in part to the current waiting times. AIMS: To determine the rate of short notice cancellation for day case surgery in a model 2 HSE hospital over a 1-month period and to implement an intervention to try and reduce the rate of cancellation. METHODS: The cancellation rate was documented over a 1-month period in the hospital. An intervention was then implemented, involving a phone call to the patient from a member of the surgical team to attempt to reduce the cancellation rate. Cancellations were re-audited after the implementation of the phone intervention. RESULTS: The initial audit revealed a cancellation rate of 39.7% during the first month prior to implementation of the phone intervention. A phone call intervention from a member of the surgical team was associated with a decrease in cancellations from 39.7 to 14.6% (p < 0.01). CONCLUSIONS: While cancellations remained high even after our intervention, a simple phone call was effective and more than halved our cancellation rate. Future efforts need to focus on increasing awareness of patient responsibility for attending scheduled appointments and procedures.

Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection.

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement.

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Biofilm-sealed perforation of the gastric body: a rare sequela of gastric band erosion.

Laparoscopic Adjustable Gastric Banding is one of the cardinal bariatric interventions and due to its early safety profile, became the mainstay. Major long-term complications of gastric banding include pouch-herniation-dilation and gastric erosion. A 59-year-old female presented to the emergency department with a 2-week history of progressive central abdominal pain and distention on a background history of a laparoscopic adjustable band insertion 11 years previously. Subsequent computed tomography demonstrated an intragastric band erosion. An exploratory laparotomy demonstrated a gastric band eroded through the stomach sealed by a biofilm. Secondary findings included small bowel ischemia and portal vein thrombosis. The gastric band was extracted, and the stomach was repaired. The ischemic small bowel was resected with primary anastomosis. The patient recovered uneventfully. Gastric band erosion should be considered in all patients presenting with abdominal pain and previous weight loss surgery. Prompt recognition may avoid fatal consequences.

Dephosphorylation/inactivation of tyrosine hydroxylase at the median eminence of the hypothalamus is required for suckling-induced prolactin and adrenocorticotrop hormone responses.

We have recently found that dopamine (DA) released from terminals of the hypothalamic neuroendocrine dopamine (NEDA) neurons plays a role not only in prolactin (PRL), but also in adrenocorticotrop hormone (ACTH) secretion, without having any influence on alpha-melanocyte-stimulating hormone (alpha-MSH) release in lactating dams. The aim of our present studies was to further investigate this DAerg regulation of ACTH using consecutively applied physiological stimulation (suckling) and pharmacological inhibition of the rate-limiting enzyme of DA synthesis (tyrosine hydroxylase, TH) by alpha-methyl-p-tyrosine (alpha-MpT) that acutely affect secretion of these pituitary hormones during lactation. Following 4h separation period, two experimental groups were formed. In the first group, lactating rats were assembled with their litters for 60 min prior to alpha-MpT. In the second group, the alpha-MpT was injected first and 60 min later suckling stimulus was applied. Plasma samples were taken in every 15 min during the 90 min experimental period. Concentrations of plasma PRL, ACTH and alpha-MSH were measured by specific RIAs. Both stimuli applied in the first sequence, significantly elevated plasma PRL and ACTH levels in separated lactating dams, without having any effect on alpha-MSH secretion. Suckling applied in the first sequence was able to block the alpha-MpT-induced elevation of ACTH secretion, while PRL response was also significantly attenuated. alpha-MpT pretreatment prevented both PRL and ACTH responses to suckling stimulus. Investigating the dephosphorylation/inactivation of TH in the arcuate nucleus-ME (TIDA) regions, no pTH-immunoreactive perikarya or terminals can be found in continuously suckled dams. In contrast, after 4h separation of the mothers from their litters, pTH-immunoreactivity can be clearly visualized in the external zone of ME. In alpha-MpT pretreated mothers following 4h separation no pTH positive terminals are visible. No changes in the TH immunostaining can be observed in any of these experimental groups. In conclusion, dephosphorylation/inactivation of TH (the rate-limiting enzyme of the DA biosynthesis) in NEDA neurons is required for suckling-induced PRL and ACTH responses.

Effect of local (intracerebral and intracerebroventricular) administration of tyrosine hydroxylase inhibitor on the neuroendocrine dopaminergic neurons and prolactin release.

BACKGROUND AND PURPOSE: Hypothalamic dopamine (DA), the physiological regulator of pituitary prolactin (PRL) secretion, is synthesized in the neuroendocrine dopaminergic neurons that projects to the median eminence and the neurointermediate lobe of the pituitary gland. The rate-limiting step of DA biosynthesis is catalyzed by the phosphorylated, therefore activated, tyrosine hydroxylase (TH) that produces L-3,4-dihydroxy-phenylalanine from tyrosine. The aims of our present study were to investigate 1. the effect of local inhibition of the DA biosynthesis in the hypothalamic arcuate nucleus on PRL release, and to get 2. some information whether the phosphorylated TH is the target of enzyme inhibition or not. METHODS: A TH inhibitor, alpha-methyl-p-tyrosine was injected either intracerebro-ventricularly or into the arcuate nucleus of freely moving rats and plasma PRL concentration was measured. Immunohistochemistry, using antibodies raised against to native as well as phosphorylated TH were used to compare their distributions in the arcuate nucleus-median eminence region. RESULTS: Intracerebro-ventricular administration of alpha-methyl-p-tyrosine has no effect, unlike the intra-arcuatus injection of enzyme inhibitor resulted in a slight but significant elevation in plasma PRL. Parallel with this, the level of DA and DOPAC were reduced in the neurointermediate lobe while no change in norepinephrine concentration can be detected indicating a reduced biosynthesis of dopamine following TH inhibition. On the other hand, systematic application of the alpha-methyl-p-tyrosine that inhibits TH activity located in DA terminals of the median eminence and the neurointermediate lobe, resulted in the most significant elevation of PRL. CONCLUSION: Our results suggest that alpha-methyl-p-tyrosine administered close to the neuroendocrine dopaminergic neurons was able to inhibit only a small proportion of the TH. Moreover, it also indicate that the majority of the activated TH can be found in the axon terminals of dopaminergic neurons, therefore, the DA released into the pituitary portal circulation is synthesized at this site.