Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries.

BACKGROUND: This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified. METHODS: Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described. RESULTS: From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage. CONCLUSION: Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

Hypothermia in open and laparoscopic colorectal surgery.

PURPOSE: Perioperative hypothermia has been shown to be an important determinant of outcome after open colorectal resections. The degree of hypothermia occurring with laparoscopic-assisted colorectal surgery is, however, unknown, and the effectiveness of standard warming measures is untested. This study was designed to assess hypothermia in open and laparoscopic-assisted colonic resections using a standardized warming protocol. METHODS: A prospective, nonrandomized study was performed with temperature measurements recorded every ten minutes. Statistical analysis was based on repeated measures analysis of variance models with significance set at the conventional 95 percent (two tailed). RESULTS: A total of 107 patients were entered into the trial; 68 had open and 39 had laparoscopic colectomies. The groups were well matched for age, weight, and duration of surgery, with a median operating time of 180 minutes in each group. The average drop in temperature from commencement of surgery to lowest point was 0.68 degrees C (standard deviation, 0.08) in the open group, compared with 0.53 degrees C (standard deviation, 0.06) in the laparoscopic group (P = 0.126). CONCLUSIONS: Laparoscopic-assisted colorectal surgery is not associated with a higher incidence of perioperative hypothermia than open colorectal surgery using a standard warming regimen for both groups. On the basis of these results, standard temperature conservation is adequate, even for long, complex laparoscopic procedures.

Laparoscopically assisted colorectal surgery in the elderly.

INTRODUCTION: Open colorectal surgery in elderly patients is associated with increased morbidity and mortality rates compared with those in younger age groups. It also requires more intensive postoperative support, longer hospitalization, and in many cases leads to prolonged rehabilitation or institutionalization. Because of its less invasive nature, laparoscopically assisted colorectal surgery may lead to a reduced period of convalescence. However, the safety of advanced laparoscopic surgical techniques in the elderly has not been established, so this prospective comparative study was undertaken. METHODS: All patients aged 80 years or more who were undergoing an elective laparoscopic or open colorectal procedure between 1 January 1992 and 30 June 1997 were assessed prospectively. Patients having simple stoma formation were excluded. Perioperative care, operative results and subsequent function were analysed. RESULTS: There were 42 patients in the laparoscopic group and 35 in the open group, with a median age of 84 years in each group. Five patients undergoing laparoscopic surgery required conversion to an open procedure. No complications related to laparoscopy occurred. Three patients died after operation in the laparoscopic group and four in the open group, with morbidity in seven and 15 patients respectively. Median hospital stay was 9 (range 4-21) days for patients having the laparoscopic operation, and 17 (range 7-28) days in the open cases. At 4 weeks after operation 30 of the 35 independent patients surviving the operation in the laparoscopic group and 16 of 28 in the open group were back to preoperative activity levels. CONCLUSION: In this series laparoscopically assisted colorectal surgery was safe and was associated with a low incidence of complications, short hospitalization and a rapid return to preoperative activity levels when compared with open colorectal resections in this age group.

Post traumatic rupture of the right main bronchus: a rare clinical entity?

Tracheobronchial disruption is an uncommon injury usually associated with severe blunt thoracic trauma and rarely occurs in isolation. We report a case of isolated rupture of the right main bronchus occurring after a crush injury without an associated pneumothorax. Difficulties in the diagnosis of this condition are briefly discussed and an algorithm of management presented.

Marsupialization of presacral collections with use of an endoscopic stapler.

Patients with anastomoses at the anorectal ring, with or without anastomotic dehiscence, may develop large presacral collections. Such collections often drain poorly through the anastomosis, leading to chronic sepsis. A novel method of widely draining such collections by "marsupialization" into the bowel lumen with use of an endoscopic stapler inserted transanally is described.

Difficult or incomplete flexible sigmoidoscopy: implications for a screening programme.

BACKGROUND: Pilot studies are currently underway to investigate the use of flexible sigmoidoscopy as a screening tool for colorectal cancer. Estimates of the sensitivity of this investigation in detecting adenomas and carcinomas frequently assume a complete examination to 60 cm in all cases. This study seeks to determine the depth of insertion of flexible sigmoidoscopy in asymptomatic volunteers, and to examine the causes and implications of an incomplete examination. METHODS: A prospective study of flexible sigmoidoscopy in asymptomatic volunteers was conducted. The maximum depth of insertion was measured in all cases, and a database compiled of patient characteristics, discomfort and endoscopic difficulty. RESULTS: Independent risk factors for reduced depth of insertion were female sex, previous abdominal surgery in females, high expectation of pain in females and poor bowel preparation. The procedure was considered difficult in 33% of cases. CONCLUSIONS: Estimates of the efficacy of flexible sigmoidoscopy as a colorectal cancer screening modality should take into account the relatively high rate of incomplete studies, particularly in women.

Early feeding after elective open colorectal resections: a prospective randomized trial.

BACKGROUND: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported. METHODS: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24-48 h. RESULTS: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty-two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group. CONCLUSION: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.

Post-cholecystectomy haemobilia: enjoying a renaissance in the laparoscopic era?

Trauma to the right hepatic artery during biliary surgery can lead to false aneurysm formation. Subsequent rupture into the biliary system, which may occur after a considerable delay, will then result in major haemobilia. This report details five cases referred to the Royal Melbourne Hospital over a 12 month period, four of which followed initial laparoscopic procedures, and emphasizes important management procedures to prevent and treat this previously rare complication.

Laparotomy for trauma in a regional centre: the effect of delay on outcome.

From 1983 to 1990, 110 patients with abdominal trauma required laparotomy in the Albury-Wodonga region. Splenic and liver injuries occurred in 50% of cases, and bowel trauma in 20%. The mortality rate was 8.2% (nine deaths) and major postoperative complications occurred in 18 patients (16%). Delay in therapeutic intervention of greater than 4 h from hospital admission led to a statistically significant increase in the complication rate (P < 0.01) despite a lower injury severity score in this group. Delayed repair of bowel injuries in particular led to an 80% major complication rate in survivors. A high index of clinical suspicion and the regular use of diagnostic peritoneal lavage is suggested to avoid such delays in diagnosis and subsequent surgery.

Delayed cerebrospinal fluid rhinorrhoea: a case report.

Post-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a well recognized complication of closed head injury. Most cases occur soon after injury and a delay in presentation of more than 1 month is unusual. A case is reported of CSF rhinorrhoea presenting 15 years after initial trauma which was complicated by meningitis after 12 months. The management of this condition is reviewed.