The Use of Clinical Parameters as Adjuncts to Endoscopic Evaluation of Mural Thickening on Conventional Computed Tomography in Diagnosing Malignancy.

BACKGROUND: Mural thickening (MT) on computed tomography (CT) poses a diagnostic dilemma in the absence of clear reporting guidelines. The aim of this study was to analyse CT reports, identifying patients in whom gastrointestinal wall MT was observed, and to correlate these reports with subsequent endoscopic evaluation. METHODS: Patients with MT who had follow-up endoscopy were included in the study (n = 308). The cohort was subdivided into upper gastrointestinal mural thickening (UGIMT) & lower gastrointestinal mural thickening (LGIMT). RESULTS: In total, 55.71% (n = 122) of colonoscopies and 61.8% (n = 55) of gastroscopies were found to be normal. Haemoglobin (HB) level in combination with MT was a predictor of neoplasia in both arms (p = 0.04 UGIMT cohort, p < 0.001 LGIMT cohort). In addition to this, age was a significant correlative parameter in both UGIMT and LGIMT cohorts (p = 0.003, p < 0.001 respectively). Dysphagia and weight loss were associated with UGI malignancies (38 and 63% respectively) and rectal bleeding was correlative in 20% of patients with LGI malignancies. CONCLUSION: HB, advancing age, and red flag symptoms are potentially useful adjuncts to MT in predicting upper and lower gastrointestinal malignancies. We propose the adoption of a streamlined pathway to delineate patients who should undergo endoscopic investigation following CT identification of MT.

The impact of COVID-19 on emergency surgical presentations in a university teaching hospital.

INTRODUCTION: The Coronavirus-19 (COVID-19) pandemic has led to a 50-70% reduction in acute non-COVID-19 presentations to emergency departments globally. AIM: To determine the impact of COVID-19 on incidence, severity, and outcomes of acute surgical admissions in an Irish University teaching hospital. METHODS: Descriptive data concerning patients presenting with acute appendicitis, diverticulitis, and cholecystitis were analysed and compared from March-May 2020 to March-May 2019. RESULTS: Acute surgical admissions decreased in March from 191 (2020) to 55 (2019) (55%), before increasing by 28% in April (2019: 119, 2020: 153). Admissions due to acute cholecystitis reduced by 33% (2019: 33, 2020: 22), with increased severity at presentation (P = 0.079) and higher 30-day readmission rates (P = 0.056) reported. Acute appendicitis presentations decreased by 44% (2019: 78, 2020: 43, P = 0.019), with an increase in severity (P < 0.001), conservative management (P < 0.001), and post-operative complications (P = 0.029) in 2020 compared to the same period in 2019. CONCLUSION: COVID-19 has potentiated a significant reduction in acute surgical presentations to our hospital. Patients presenting with acute appendicitis during the pandemic had more severe disease, were more likely to have complications, and were significantly more likely to be managed conservatively when compared to historical data.

Negative appendicectomy rates as a quality measure in a regional surgical unit: a retrospective review.

INTRODUCTION: Historically, high negative appendicectomy rates (NAR) were acceptable to offset the risks of perforation, previously exceeding 20%. With improved imaging and clinical scoring algorithms, there is growing demand for lower negative appendicectomy rates. The objectives were to (1) establish the NAR in our institution and (2) correlate clinical parameters and imaging modalities with histological findings. METHODS: Patients undergoing an appendicectomy between January 2012 and June 2018 were identified using a prospectively maintained pathology database. Histology findings were cross referenced against our radiology system, and anonymised data was collected for gender, age, WCC, Neutrophil and CRP level. RESULTS: One thousand one hundred fifty-three patients met the inclusion criteria. Fifty-three percent were males (n = 610), with 81% (n = 933) of histology reports classified as appendicitis. Sixty patients had a histologically normal appendix equating to a 5.2% NAR. If lymphoid hyperplasia, fibrosis and atrophy are included, it equates to a NAR of 14.57%. (p < 0.0001). Sixty-six percent of patients had no pre-operative imaging. CT imaging demonstrated a higher sensitivity (93.33%) and positive predictive value (99.60%) compared to ultrasonography. WCC and CRP are statistically significant in predicting appendicitis (p < 0.0001). CONCLUSION: There is no consensus on defining a negative appendicectomy or for imaging modality utilisation. CT imaging is the most sensitive and should be used in cases of diagnostic uncertainty. A standardised algorithm regarding the workup of patients with RIF pain along with a consensus on the use of imaging will further reduce negative appendicectomy rates.

The future of general surgery in Ireland: factors influencing career decisions of medical students.

INTRODUCTION: The decline in popularity of general surgery as a career has been well described. A number of factors have been put forward to explain this, for example, trainee burnout and perceived difficulty with work/life balance. The aim of this study was to elucidate the reasons for this among medical students in Ireland. METHOD: A questionnaire was distributed to clinical year medical students in Ireland using an online survey via SurveyMonkey™. Domains assessed included demographics, career plan and associated rationale. Anonymised responses were collated and evaluated. RESULTS: There were 307 responses (response 23%). Females accounted for 66% (202). Mean age was 24 years (SD = 2.89). One hundred twelve responses (36%) were contemplating becoming surgeons. One hundred nine-five responses were not considering surgery: however 87 had previously considered. Of the 87, 41 (47%) attributed the decision to work/life balance, 30 (35%) to impact on personal relationships and 10 (11%) blamed unclear career projection. Students interested in surgery were asked to quantify their knowledge of the application process-17 (15%) good, 39 (35%) fair and 56 (50%) poor. CONCLUSION: A small proportion of respondents plan to pursue a career in general surgery. This is concerning in view of attrition rates through junior years. Although lifestyle factors are significant, clarity regarding training pathways was also reported. Undergraduate education regarding career trajectory, quality of life and practicalities of a career in general surgery may increase applications.

Benign cyst with xanthogranulomatous inflammation involving the transverse colon and the common iliac artery.

Xanthogranulomatous inflammation (XGI) is a rare process. Colonic XGI is extremely rare. We present a case report of XGI arising within an intra-abdominal cyst involving the transverse colon. A 28-year-old man presented with abdominal discomfort. He underwent a computed tomography abdomen-pelvis, which found three subcutaneous collections and a large cystic intra-abdominal structure. The decision was made for resection. Intraoperatively, the cyst originated from the pelvis and was adherent to the surrounding tissues. Histology from the lesion revealed XGI extending into the surrounding tissue. XGI is a rare inflammatory condition. Clinically, it can be difficult to distinguish XGI from an infiltrative malignancy. Therefore, it is usually necessary to obtain a pathological diagnosis of XGI. This case describes an atypical cystic lesion with XGI involving the transverse colon. Although rare, it should be considered in the potential differential diagnosis of an infective or malignant mesenteric cyst.