Karydakis flap for post-proctectomy perineal sinus: A case series and review.

INTRODUCTION: Persistent perineal sinus (PPS) may occur in up to 38% of patients undergoing proctectomy. The available therapeutic options range from simple but ineffective to relatively successful but complex. The Karydakis procedure is a straightforward day-case operation, commonly performed by general surgeons in the treatment of pilonidal disease, a not dissimilar pathology to PPS. This report is the first in the literature describing the use of Karydakis procedure in patients who developed PPS after proctectomy for Crohn's disease. PRESENTATION OF CASE: Two patients, both of whom suffered from Crohn's disease and a PPS, underwent a Karydakis procedure as first-line treatment for PPS. Case 1 had a relatively superficial PPS while Case 2 had a deeper, more complex and longstanding PPS. Both patients had no post-operative complications and were discharged on the same day. They achieved complete healing in eight weeks and eight months respectively. The follow up range was 8-16 months. DISCUSSION: Various techniques, including complex myocutaneous flap reconstruction, have been described in the literature to treat PPS. In contrast to these complex techniques, Karydakis operation is a simple day case procedure that was successful in treating PPS in our patients. While there is robust data regarding low recurrence rates following a Karydakis flap for pilonidal disease, there is no existing data for the indication outlined in this report. CONCLUSION: While it requires further assessment, the Karydakis operation has potential as a simple, safe and effective first-line treatment in selected patients with PPS while not precluding more complex operative options in the future.

Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery.

INTRODUCTION: An anaerobic threshold (AT) of <11 ml/min/kg can identify patients at high risk of cardiopulmonary complications after major surgery. The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting cardiopulmonary complications in high risk patients undergoing oesophagogastric cancer resection. METHODS: Between March 2008 and October 2010, 108 patients (83 men, 25 women) with a median age of 66 years (range: 38-84 years) underwent CPET before potentially curative resections for oesophagogastric cancers. Measured CPET variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Outcome measures were length of high dependency unit stay, length of hospital stay, unplanned intensive care unit (ICU) admission, and postoperative morbidity and mortality. RESULTS: The mean AT and VO2 peak were 10.8 ml/min/kg (standard deviation [SD]: 2.8 ml/min/kg, range: 4.6-19.3 ml/min/kg) and 15.2 ml/min/kg (SD: 5.3 ml/min/kg, range: 5.4-33.3 ml/min/kg) respectively; 57 patients (55%) had an AT of <11 ml/min/kg and 26 (12%) had an AT of <9 ml/min/kg. Postoperative complications occurred in 57 patients (29 cardiopulmonary [28%] and 28 non-cardiopulmonary [27%]). Four patients (4%) died in hospital and 21 (20%) required an unplanned ICU admission. Cardiopulmonary complications occurred in 42% of patients with an AT of <9 ml/min/kg compared with 29% of patients with an AT of ≥9 ml/min/kg but <11 ml/min/kg and 20% of patients with an AT of ≥11 ml/min/kg (p = 0.04). There was a trend that those with an AT of <11 ml/min/kg and a low VO2 peak had a higher rate of unplanned ICU admission. CONCLUSIONS: This study has shown a correlation between AT and the development of cardiopulmonary complications although the discriminatory ability was low.

The use of self-expanding plastic stents in the management of oesophageal leaks and spontaneous oesophageal perforations.

Leakage after oesophageal anastomosis or perforation remains a challenge for the surgeon. Traditional management has been operative repair or intensive conservative management. Both treatments are associated with prolonged hospitalisation and high morbidity and mortality rates. Self-expanding metallic stents have played an important role in the palliation of malignant oesophageal strictures and the treatment of tracheoesophageal fistulae. However, self-expanding metal stents in benign oesophageal disease are associated with complications such as bleeding, food bolus impaction, stent migration, and difficulty in retrieval. The Polyflex stent is the only commercially available self-expanding plastic stent which has been used in the management of malignant oesophageal strictures with good results. This review will consider the literature concerning the use of self-expanding plastic stents in the treatment of oesophageal anastomotic leakage and spontaneous perforations of the oesophagus.

Still waiting for predictive biomarkers in Barrett's oesophagus.

Barrett's oesophagus is important as a precursor of oesophageal adenocarcinoma via a metaplasia-dysplasia-carcinoma sequence. It is often detected on upper gastrointestinal endoscopy. In the absence of glandular dysplasia the risk of progression to cancer is low but ascertainment of dysplasia is not always straightforward. Sparse mucosal sampling may miss dysplasia, or reactive changes may be overinterpreted due to inter and intraobserver variation. Low-grade and even high-grade dysplasia do not necessarily progress, provided prevalent cancer has been rigorously excluded. This indeterminacy motivates an ongoing search for clinically useful predictive biomarkers. Although many genetic and epigenetic abnormalities have been associated with neoplastic progression in Barrett's mucosa no molecular tests have as yet been accepted into routine pathology practice. Challenges of assay definition remain and many marker studies lack statistical power or have other methodological flaws. Even where strong evidence of clinically relevant predictive value does exist (in the case of ploidy analysis by flow or image cytometry) adoption has been minimal, likely reflecting technological and possible reimbursement obstacles. Well designed multicentre studies are likely to be required to translate improved knowledge of Barrett's carcinogenesis into clinically significant progress on predictive testing, and will require a degree of cooperation not so far widely seen in the field.

Proposed follow up programme after curative resection for lower third oesophageal cancer.

The incidence of oesophageal adenocarcinoma has risen throughout the Western world over the last three decades. The prognosis remains poor as many patients are elderly and present with advanced disease. Those patients who are suitable for resection remain at high risk of disease recurrence. It is important that cancer patients take part in a follow up protocol to detect disease recurrence, offer psychological support, manage nutritional disorders and facilitate audit of surgical outcomes. Despite the recognition that regular postoperative follow up plays a key role in ongoing care of cancer patients, there is little consensus on the nature of the process. This paper reviews the published literature to determine the optimal timing and type of patient follow up for those after curative oesophageal resection.

Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer.

The presence of systemic inflammation before surgery, as evidenced by the glasgow prognostic score (mGPS), predicts poor long-term survival in colorectal cancer. The aim was to examine the relationship between the preoperative mGPS and the development of postoperative complications in patients undergoing potentially curative resection for colorectal cancer. Patients (n=455) who underwent potentially curative resections between 2003 and 2007 were assessed consecutively, and details were recorded in a database. The majority of patients presented for elective surgery (85%) were over the age of 65 years (70%), were male (58%), were deprived (53%), and had TNM stage I/II disease (61%), had preoperative haemoglobin (56%), white cell count (87%) and mGPS 0 (58%) in the normal range. After surgery, 86 (19%) patients developed a postoperative complication; 70 (81%) of which were infectious complications. On multivariate analysis, peritoneal soiling (P<0.01), elevated preoperative white cell count (P<0.05) and mGPS (P<0.01) were independently associated with increased risk of developing a postoperative infection. In elective patients, only the mGPS (OR=1.75, 95% CI=1.17-2.63, P=0.007) was significantly associated with increased risk of developing a postoperative infection. Preoperative elevated mGPS predicts increased postoperative infectious complications in patients undergoing potentially curative resection for colorectal cancer.

A review of surgical nutrition.

Malnutrition remains a common problem in surgical patients and is associated with significant morbidity and mortality. It is imperative that all surgical patients undergo nutritional screening on admission to highlight malnourished or at risk patients and implement a nutritional plan. Nutrition can be delivered by oral supplements, enteral or parenteral feeding, the route depending on an individual's requirements and surgical condition. Enteral feeding has largely been regarded as superior to parenteral feeding, as it is cheaper, safer and "more physiological" but studies show this is not always the case. This article reviews the basics of surgical nutrition and assesses the evidence supporting enteral versus parenteral nutrition.

Intraoperative retrograde mesenteric angioplasty for acute occlusive mesenteric ischaemia: a case series.

Acute mesenteric ischaemia secondary to atherosclerotic disease of the superior mesenteric artery is a surgical emergency associated with a poor prognosis, and requires prompt diagnosis and early revascularisation in order to improve outcome. The traditional management of surgical resection of necrotic bowel plus mesenteric revascularisation by surgical bypass is associated with significant morbidity and mortality. We describe the use of a combined surgical and endovascular approach, using intraoperative retrograde superior mesenteric angioplasty at the time of laparotomy. Four patients have been treated by this combined technique with three surviving, although one subsequently required an open surgical revascularisation procedure.

Perineal metastatic Crohn's disease: a case report and review of the literature.

Metastatic Crohn's disease is an uncommon complication of Crohn's disease defined as granulomatous inflammation not contiguous with inflammatory disease in bowel. We report on the presentation and management of a 36-year-old man, who had undergone panproctocolectomy 11 years ago, with complex fistulous disease in his perineum, which demonstrated granulomas histologically after resection. We review six similar case reports. Optimal treatment would appear to be by surgical debridement.