Local Protocol for Management of Low-Grade Appendiceal Mucinous Neoplasm (LAMN).

The management and surveillance of low-grade appendiceal mucinous neoplasm (LAMN) is a confusing topic in the colorectal MDM. This study was aiming to provide a local protocol for our trust for such cases. From prospectively maintained database, patients who underwent appendicectomy between 2011 and 2017 were identified. Those with histological confirmation of LAMN were included. Retrospective analysis of operative notes, investigations and follow-up, return to theatres or development of pseudomyxoma peritonei (PMP) was performed. Four thousand six hundred twenty-eight patients had appendicectomy; 36 were diagnosed with LAMN. Age range was 30-88 (20 females). Fifteen had their operation as emergency and 13 elective, either for abnormal-looking appendix on CT scan or as part of elective right hemicolectomy. In 8 patients, LAMNs were diagnosed incidentally during other surgery either intraoperatively or on histology. Two patients had mucus in the peritoneal cavity (not sampled). The remaining 34 had either contained mucocele or inflamed appendix. Regarding follow-up, 28 patients had CT scans only, and 2 had ultrasound scan (USS). Two had both CT and USS. Three had CT and MRI scans. One patient did not have radiological investigations. Eighteen patients had colonoscopies (50%). Three patients had no follow-up, while 33 had 5-year follow-up. Ten patients are still currently under follow-up. None of the 36 patients required further surgeries related to LAMN, and none has developed PMP to date of the study. We have developed a local protocol based on our findings and literature review for management and surveillance of LAMN in line with national centres.

Stomach in a parastomal hernia: a rare complication of stomas.

Parastomal hernia (PSH) is one of the most known complications to end colostomies. However, PSH containing the stomach is rare: not many case reports were found in literature search. This case is a 92-year-old woman who was brought in by ambulance to the accident and emergency department with vomiting, abdominal distension, palpable mass on the left side of her abdomen and with reduced stoma effluent. Her abdominal CT scan showed a PSH containing a partially incarcerated gastric hernia. Although there are only few similar cases of PSH containing the stomach reported in the literature, an almost similar pattern in presentation of this unique case can be deduced following a thorough comparison of cases in the literature, which can be quite helpful both academically and clinically: they are often advanced in age and are usually women with end colostomies.

A 2-week wait referral diagnosed with post-sternotomy liver herniation in a background of adrenal myelolipoma.

Herniation of the liver through the anterior abdominal wall is a rare post-sternotomy complication. A 32-year-old woman had a 2-week wait referral due to abdominal pain, weight loss and upper abdominal swelling. She was known to have a left adrenal myelolipoma and had a mitral valve replacement 3 years prior to presentation with the postoperative period complicated by sepsis and poor wound healing. She had recently been started on metformin for type 2 diabetes mellitus and she had long-standing lower abdominal symptoms known to the gynaecology team. Investigations revealed hepatic herniation of liver segments II & III through the anterior abdominal wall while there was no underlying malignancy a benign left adrenal myelolipoma was noted.

Quality improvement measures: effects on rectal cancer tissue biopsy process.

PURPOSE: Delay in histologically confirming rectal cancer may lead to late treatment as histological confirmation is required prior to chemo-radiotherapy or surgical intervention. Multidisciplinary colorectal meetings indicate that there are patients who require multiple tissue biopsy episodes prior to histologically confirming rectal cancer. The purpose of this paper is to examine a quality improvement (QI) measure's impact on tissue biopsy process diagnostic yield. DESIGN/METHODOLOGY/APPROACH: The authors performed the study in two phases (pre- and post-QI), between February 2012 and April 2014 in a district general hospital. The QI measures were derived from process mapping a rectal cancer diagnostic pathway. The primary outcome was to assess the tissue biopsy process diagnostic yield. The secondary outcome included total breaches for a 62-day target in the pre- and post-QI study phases. FINDINGS: There was no significant difference in demographics or referral mode in both study phases. There were 81 patients in the pre-QI phase compared to 38 in the post-QI phase, 68 per cent and 74 per cent were referred via the two-week wait urgent pathway, respectively. Diagnostic tissue biopsy process yield improved from 58.1 to 77.6 per cent after implementing the QI measure ( p=0.02). The 62-day target breach was reduced from 14.8 to 3.5 per cent ( p=0.42). PRACTICAL IMPLICATIONS: Simple QI measures can achieve significant improvements in rectal cancer diagnostic tissue biopsy process yields. A multidisciplinary approach, involving process mapping and cause and effect modelling, proved useful tools. ORIGINALITY/VALUE: A process mapping exercise and QI measures resulted in significant improvements in diagnostic yield, reducing the episodes per patient before histological diagnosis was confirmed.

Right and Transverse Colonic Multi-Visceral Resections for Locally Advanced Cancers-a Single-Center Experience.

Locally advanced colorectal tumors constitute to about 5-22% of all colorectal cancers at the time of presentation. Multi-visceral resection is usually required for such cases in order to achieve curative resection (R0). We aim to present our experience of right and transverse colonic en bloc resections and their outcomes. Retrospective review of a prospective database between February 2008 and December 2014. Case notes, operative findings, histopathology results, and follow-up records were analyzed. A total of 23 patients underwent en bloc multi-visceral resections for locally advanced right-sided or transverse colonic cancers. There were 11 males and 12 females. The mean age was 75 years. Fifteen patients were operated electively and eight were done as emergency. Median follow-up was 36 months. Eleven out of 23 (47%) had more than one organ resected. 78.3% had R0 resections, 17.4% were R1, and 4.3% were indeterminate. The average lymph node yield was 22 [range 5-45]. Senior trainees under supervision did 65% of procedures. Twelve-month disease-free survival was 90% and the 5-year survival was 65%. Right-sided and transverse colonic tumors have a propensity to become locally advanced making curative resections challenging. This is especially relevant when these patients present as an emergency or if the surgeon is less experienced and may opt for a palliative procedure, thus leading to suboptimal outcomes. Multi-visceral resections for locally advanced tumors can be feasible in the district general hospital setting with acceptable outcomes. Multi-disciplinary meeting (MDM) process, adequate training, and experience are vital.

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience.

OBJECTIVES: To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF. METHODS: Medline and Embase database were searched for the words 'pilonidal, sinus, Limberg, flap'. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected. RESULTS: Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0-7.4% in case series. Recurrence rate in comparative studies was 0-8.3%, compared to 4-37.7% for primary closure and 0-11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% - [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months. CONCLUSIONS: Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.

Evaluation of Platelet Indices and Red Cell Distribution Width as New Biomarkers for the Diagnosis of Acute Appendicitis.

BACKGROUND: Debate around the value of laboratory tests in establishing the diagnosis of acute appendicitis (AA) still continues. This prospective study aimed to investigate the changes in mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW) with the diagnosis of acute appendicitis. METHOD: 200 patients who underwent emergency appendectomy were included. According to postoperative histology, patients were divided into three groups: acute non-complicated, acute complicated appendicitis (positive appendicectomy groups), and negative appendectomy group. White blood cell (WBC), neutrophil, lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), platelets (PLT) count, MPV, PDW, RDW, and C-reactive protein (CRP) were compared among the groups. RESULTS: One hundred twenty-five (62.5%) patients had non-complicated acute appendicitis, 20 (10%) had complicated acute appendicitis, while 55 (27.5%) had normal appendix. WBC (p <.001), neutrophil (p <.001), NLR (p <.001), PDW (p =.003), and CRP (p =.001) were higher, while lymphocyte (p <.001) and PLT counts (p =.020) were lower in positive appendectomy compared with negative appendectomy patients. MPV levels were insignificantly different across the groups. RDW level was significantly higher in complicated compared with non-complicated acute appendicitis (p =.006); however, no significant difference was found between positive and negative appendectomy groups. Using receiver operating characteristic analysis, sensitivity, specificity, and diagnostic accuracy respectively were 44.83, 100.0, and 72.415% for WBC count, 72.41, 81.82, and 77.115% for neutrophil count, 48.28, 90.91, and 69.595% for PDW, 89.66, 63.64, and 76.65% for CRP. CONCLUSIONS: Increased PDW combined with elevated WBC and neutrophil counts maybe used as diagnostic tests in the cases of acute appendicitis, while MPV and RDW levels were not useful diagnostic markers.

Financial Burden Secondary to Delay in Cholecystectomy Following Mild Biliary Pancreatitis.

AIM OF THE STUDY: The guidelines recommend that patients with mild gallstones pancreatitis should undergo a definitive management for gallstones during the same admission or within the next two weeks. The aim of this study was to estimate the financial cost resulting from a delay in surgical management following mild gallstones pancreatitis. This includes the costs of readmissions with biliary events and the subsequent investigations required during these admissions. MATERIALS AND METHODS: A retrospective analysis included patients with gallstone pancreatitis who were admitted to a district general hospital in the United Kingdom over one year. Patients with severe pancreatitis and those unfit for surgery were excluded. RESULTS: Forty patients were included in the study, 27 females (67%) and 13 males (33%). Mean age was 50.2 years. Twenty-two patients of the total presented with a single admission with gallstone pancreatitis prior to an elective surgery; however, 18 patients (45%) required recurrent admissions. The duration between the first admission and surgery ranged from 14 to 389 days (median of 99 days). Only one patient (2.5%) had cholecystectomy within two weeks of admission as per guidelines. Twenty-two ultrasound scans, four computed tomography scans, 15 magnetic resonance cholangiopancreatography, and two endoscopic retrograde cholangiopancreatography were the total of the extra-investigations required during readmissions. Estimated costs of extra admissions and extra investigations exceeded £33,000. CONCLUSIONS: The delay in cholecystectomy for patients admitted with mild gallstone pancreatitis and fit for surgery has resulted in high readmission rate with biliary events, and subsequently high extrax costs.

Patient-related factors influence the risk of developing intestinal stoma complications in early post-operative period.

BACKGROUND: Few studies have investigated the risk factors associated with developing intestinal stoma complications using appropriate multivariable methods. We aimed to determine the prevalence of, and risk factors for, stomal complications. METHODS: A retrospective, case-control methodology was used to investigate 12 explanatory variables and four outcome variables in 202 consecutive patients receiving stomas in a district general hospital in the United Kingdom between January 2013 and December 2014. Univariable and multivariable logistic regression were used to calculate odds ratios (ORs). RESULTS: There were 69 complications (69/202; 34.2%) in the early post-operative period (median 12 months) in total, the most common being retraction (30.4%). Performance status (World Health Organization score 1 or more; OR 2.67; 95% confidence intervals (CIs) 1.33-5.33; P = 0.006) and body mass index (>30 kg/m2 ; OR 3.30; 95% CIs 1.61-6.78; P = 0.001) were significantly associated with developing complications in multivariable analysis. Surgery-related risk factors, such as time of day or week of operation and grade of surgeon, were not associated with the development of stoma complications. Thirty-eight patients (18.8%) died over the follow-up period, but mortality was not related to the development of stoma complications (1.01; 0.48-2.13, P = 0.98). CONCLUSION: Patient-related risk factors influence the risk of developing a stoma complication more than surgery-related risk factors. Preoperative and post-operative interventions, planning, vigilance and management should be focussed to at-risk groups, particularly obese patients.

Prevascular femoral hernia and its relation with inferior epigastric vessels: a rare presentation of the femoral hernia sac.

A 61-year-old man presented to the emergency department, with a 2-week history of a painful lump on his right groin. A diagnosis of an irreducible right femoral hernia was made. As such, an urgent operation was carried out on the same day, and the patient was found to have a rare prevascular femoral hernia in which the sac was lying over the femoral vessels and split by the inferior epigastric vessels into 2 components resembling 2 trouser limbs. The hernia sac presented in a different and challenging way that necessitated meticulous dissection and full orientation of the anatomy of the femoral triangle. Complete dissection and control of the inferior epigastric vessels, and complete reduction of the sac followed by repair with a prosthetic mesh plug were performed successfully. The patient was discharged home the next day.

Utilisation of the falciform ligament pedicle flap as an alternative approach for the repair of a perforated gastric ulcer.

An 83-year-old woman presented to the emergency department with sudden onset of severe abdominal pain. She had a background of ulcerative colitis managed surgically at the age of 18 years with panproctocolectomy and permanent ileostomy. On admission, clinical assessment suggested a visceral perforation and an urgent CT scan demonstrated a perforated prepyloric ulcer. Emergency laparotomy was performed and confirmed a 3 cm perforated pre-pyloric ulcer. Repair of the defect was challenging due to the absence of omental fat to patch the perforation. A modification to the standard technique was therefore performed: the falciform ligament was mobilised and its free end used as a patch to repair the defect. The patient made a good postoperative recovery. This case report highlights an alternative operative technique for the treatment of perforated gastric/duodenal ulcers in patients who lack omentum, or when omentum cannot be used to cover perforated gastroduodenal ulcers.