Negative pressure wound therapy following excision of pilonidal sinus disease: A retrospective review.

AIM: There is no agreed definitive surgical treatment for pilonidal sinus disease (PSD) with several techniques in use with varying success. Negative pressure wound therapy (NPWT) is used to accelerate wound healing but literature in the context of PSD remains sparse. The aim of this study was to evaluate outcomes in patients with PSD treated by a standardised technique of complete surgical excision followed by the application of NPWT. METHODS: A retrospective observational cohort study of all patients with PSD managed by complete surgical excision followed by application of NPWT was performed over a five year period. The primary endpoints were PSD recurrence and failed wound healing. RESULTS: Sixty-one patients underwent treatment during the study period. There was 100% compliance with NPWT. All patients' wounds healed successfully, with the median time to healing being 28 days. One patient (1.6%) developed recurrent PSD and required further surgery. Two patients (3.3%) developed postoperative wound infections. Five patients, who had been managed previously by other operative approaches and subsequently developed recurrence, were successfully managed by this technique. Most patients (52.4%) were managed as a day case procedure. CONCLUSIONS: Surgery for PSD should have low recurrence rates, prompt wound healing, minimal complications, short inpatient lengths of stay and be tolerated by the patient. Our results demonstrate that our technique meets these criteria. To our knowledge, this study contains the largest number of patients with PSD managed by excision and NPWT in the literature.

Routine Endoscopy After Acute Sigmoid Diverticulitis: Would a Sigmoidoscopy be Sufficient?

BACKGROUND:  Current guidelines suggest that patients should undergo colonoscopy after CT confirmed acute diverticulitis to outrule colorectal cancer (CRC). The aim of this study was to determine if flexible sigmoidoscopy (FS) could be a viable alternative to full colonoscopy following acute sigmoid diverticulitis. METHODS:  A retrospective study of 271 patients was performed who were diagnosed with acute sigmoid diverticulitis by CT and subsequently underwent full colonoscopy. Medical records, CT reports, endoscopy reports, and histopathological reports were reviewed. RESULTS:  Sigmoid diverticulosis was confirmed on colonoscopy in all patients. No colorectal malignancies were detected. Adenomatous polyps were found in 16 (5.9%) patients, of which three had polyps detected beyond the sigmoid colon. The overall proportion of abnormalities found beyond the sigmoid colon was 1.1% (n=3). CONCLUSION:  The detection of CRC cancer in patients undergoing full colonoscopy following an episode of acute sigmoid diverticulitis is rare. Despite this, current guidelines still advocate for endoscopy due to the potentially serious consequences of a missed malignancy. However, given that the area of concern in these cases is the sigmoid colon, FS may be a feasible means of outruling malignancy in the absence of red flag features that would necessitate a full colonoscopy. Our results support this approach, with no CRC detected and a polyp detection rate equivalent to that of the general population. This offers numerous advantages to a full colonoscopy for the patient and health service by being a quicker, cheaper, safer procedure without the need for full bowel preparation or IV sedation.

Laparoscopic totally extraperitoneal hernia repair performed by surgical trainees: overcoming the learning curve.

BACKGROUND: Surgical trainees struggle to obtain experience in laparoscopic inguinal hernia repair (LIHR) due to a perceived steep learning curve. The purpose of this study was to compare outcomes in totally extraperitoneal (TEP) repair performed by surgical consultants and trainees under supervision as part of a standardised training regimen to assess the safety of residency training in this technique. METHODS: A retrospective review of patients managed by TEP repair by either a consultant or a supervised trainee was performed. Demographic, perioperative and postoperative data were collected and compared. All trainees underwent a standardised approach to teaching TEP repair. RESULTS: Trainees performed 133 procedures and consultants performed 121 procedures. Estimated blood loss was minimal in both cohorts. A significant difference was noted in mean operating time between consultants and trainees (33 vs. 50 min). However, it was also observed that the trainee mean operating time reduced significantly with experience (from 61 to 42 min). No statistically significant difference was demonstrated in postoperative complications, recurrence rate or length of stay. All trainees achieved the ability to complete a laparoscopic TEP repair under unscrubbed consultant supervision during a 1-year placement. CONCLUSION: With senior supervision and in the presence of a structured training regimen, trainees can safely and effectively perform LIHR, progressing to performing the procedure under unscrubbed consultant supervision. This is valuable information that can serve to inform the structure and direction of surgical training programmes as the ability to offer LIHR is increasingly becoming an expectation of consultant surgeons.

The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis.

The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I2 = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.

Diagnostic Inaccuracies of Barrett's Oesophagus on Gastroscopy: Are We Performing Unnecessary Surveillance?

Background It is common for patients to enter Barrett's oesophagus (BO) surveillance based on endoscopic appearances before the diagnosis is histologically confirmed. We set out to review this practice by establishing the accuracy of endoscopic diagnoses of BO. Methods All gastroscopy reports in which a diagnosis of BO was recorded were reviewed over one year. These were compared to the histopathological reports to assess diagnostic accuracy. Results BO was diagnosed in 84 procedures. This diagnosis was incorrect according to histology in 42.9% (n=36) of cases. Diagnostic accuracy was higher with gastroenterologists (38.8% incorrect, n=21) compared to surgeons (50% incorrect, n=15). Diagnostic accuracy was higher with consultants (34.9% incorrect, n=22) compared to registrars (66.7% incorrect, n=14). The dose of sedation used had no impact on accuracy. Unnecessary surveillance was booked in 36.1% (n=13) of cases. Conclusion It is insufficient to rely on endoscopic appearances alone to diagnose BO, irrespective of speciality or experience. The diagnosis should only be made after reviewing the histopathology report. This can eliminate unnecessary repeat endoscopy procedures, sparing patients from unjustifiable risk and helping to cut down on long waiting lists in endoscopy departments. The implementation of the Prague classification and Seattle protocol can improve diagnostic accuracy.

The dilemma of the duplicated cystic duct: a case report.

We present a rare case of a duplicated cystic duct encountered during an elective laparoscopic cholecystectomy in a patient with biliary colic. Prompt recognition of an intraoperative bile leak followed by thorough examination and recognition of the source allowed for timely and appropriate management of the affected patient with a satisfactory post-operative outcome. Our case is unique by the lack of availability of intraoperative cholangiogram at the time of surgery, which posed a significant diagnostic and therapeutic challenge, and by how aberrant anatomy was confirmed intraoperatively by reviewing prior cardiac magnetic resonance imaging. Unremarkable preoperative imaging does not rule out the presence of abnormal anatomy. Early involvement of a specialist hepatobiliary surgeon is essential in an unexplained bile leak, with a low threshold in converting to an open procedure if there is difficulty in clearly deciphering anatomy.

Spatial regulation of Galphai protein signaling in clathrin-coated membrane microdomains containing GAIP.

Regulators of G-protein signaling (RGS) proteins are GTPase-activating proteins (GAPs) that bind to Galpha subunits and attenuate G protein signaling, but where these events occur in the cell is not yet established. Here we investigated, by immunofluorescence labeling and deconvolution analysis, the site at which endogenous Galpha-interacting protein (GAIP) (RGS19) binds to Galphai3-YFP and its fate after activation of delta-opioid receptor (DOR). In the absence of agonist, GAIP is spatially segregated from Galphai3 and DOR in clathrin-coated domains (CCPs) of the cell membrane (PM), whereas Galphai3-YPF and DOR are located in non-clathrin-coated microdomains of the PM. Upon addition of agonist, Galphai3 partially colocalizes with GAIP in CCPs at the PM. When endocytosis is blocked by expression of a dynamin mutant [dyn(K44A)], there is a striking overlap in the distribution of DOR and Galphai3-YFP with GAIP in CCPs. Moreover, Galphai3-YFP and GAIP form a coprecipitable complex. Our results support a model whereby, after agonist addition, DOR and Galphai3 move together into CCPs where Galphai3 and GAIP meet and turn off G protein signaling. Subsequently, Galphai3 returns to non-clathrin-coated microdomains of the PM, GAIP remains stably associated with CCPs, and DOR is internalized via clathrin-coated vesicles. This constitutes a novel mechanism for regulation of Galpha signaling through spatial segregation of a GAP in clathrin-coated pits.