The history of surgery and surgical training in the UK.

Surgery has a rich history, and in order to understand the various training pathways for aspiring surgeons one must have an appreciation of the evolution of surgery. This manuscript aims to deliver a brief review of the history of surgery, and explore the historical moments that have shaped the training pathway of surgeons in the United Kingdom (UK), and in doing so disseminate the latest information about surgical training in the UK.

A mesh masquerading as malignancy: a cancer misdiagnosed.

After a positive faecal occult blood test, a 60-year-old woman underwent a screening colonoscopy which identified a malignant-looking ulcer in the ascending colon. Biopsies from the lesion were inconclusive. A subsequent CT scan of the abdomen and pelvis commented on a polypoid lesion in the ascending colon. A colorectal cancer multidisciplinary team discussion concluded that a right hemicolectomy was indicated as the lesion was suspicious for malignancy. Intraoperatively, there was a firm ascending colon mass adherent to the abdominal wall, which was resected with clear margins. There were no other complications, and the patient was discharged without further issues. Histopathology from the retrieved specimen revealed a complete absence of malignancy, but rather, inflamed granulation tissue with 'reaction to foreign birefringent material'-likely to represent a mesh from an incisional hernia repair 9 years previously. The patient is currently recovering well without complication.

A single centre case series of gallstone sigmoid ileus management.

AIMS/INTRODUCTION: Gallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel. We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management. METHODS: Cases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines. RESULTS: 3 patients - 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula. Patient 1: Unsuccessful endoscopic attempts to retrieve the (5×5cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy. Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction. Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6days post-operation. CONCLUSIONS: This is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients' needs given the complexities of this potentially life threatening condition.

Appendicular sarcoidosis mimicking acute appendicitis.

Appendicular sarcoidosis is a very rare cause of acute abdominal pain, with only seven cases reported previously in the literature. A 45-year-old woman, known to have sarcoidosis, presented to the emergency department with a 1-week history of epigastric and right iliac fossa abdominal pain. At diagnostic laparoscopy, an acutely inflamed appendix was found and removed as well as an omental mass which was biopsied. Subsequent histopathological examination of the appendix demonstrated appendicular sarcoidosis without acute appendicitis and chronic inflammatory changes in the omental biopsy. The patients' symptoms completely resolved postoperatively. It is important to undertake urgent operative intervention in patients with sarcoidosis who present with right iliac fossa pain, owing to the high risk of perforation.

Laparoscopic vs open appendectomy in older patients.

HYPOTHESIS: The results of a meta-analysis of individual studies comparing laparoscopic vs open appendectomy in older patients may guide the choice of surgical approach. DESIGN: Meta-analysis. SETTING: Academic research. PATIENTS: MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for comparative studies of older patients with a diagnosis of acute appendicitis. MAIN OUTCOME MEASURES: Primary outcomes were postoperative mortality and overall morbidity. Secondary outcomes were operative time, length of hospital stay, postoperative wound infection, and intra-abdominal collection. Using the lowest threshold from the articles included, older patients were defined as those older than 60 years. RESULTS: Analyzed were 6 studies comprising 15 852 appendectomies (4398 laparoscopic and 11 454 open procedures). Laparoscopic appendectomy was associated with significant reductions in postoperative mortality (pooled odds ratio, 0.24; 95% CI, 0.15-0.37), postoperative complications (pooled odds ratio, 0.61; 95% CI, 0.50-0.73), and length of hospital stay (weighted mean difference, -0.51 days; 95% CI, -0.64 to -0.37 days) (P < .05 for all). No significant group differences were observed in operative time, postoperative wound infection, or intra-abdominal collection. CONCLUSIONS: In older patients, laparoscopic appendectomy is associated with reduced postoperative mortality and morbidity, although randomized data are required to infer causality. A health economic analysis with quality-of-life metrics is needed to investigate potential benefits of the reduced length of hospital stay observed following laparoscopic appendectomy in this cohort.