A cohort study investigating the relationship between patient reported outcome measures and pre-operative frailty in patients with operable, non-palliative colorectal cancer.

BACKGROUND: Frailty refers to the reduction in homeostatic reserve resulting from an accumulation of physiological deficits over a lifetime. Frailty is common in older patients undergoing surgery and is an independent risk factor for post-operative mortality, morbidity and increased length of hospital stay. In frail individuals, stressors, such as surgery, can precipitate an acute deterioration in health, manifesting as delirium, falls, reduction in mobility or continence, rendering these individuals at an increased risk of adverse perioperative outcomes. However, little is known about how frailty affects the patient experience, functional ability and quality of life (QoL) after surgery. In addition, the distribution of frailty in this population is unknown. METHODS: We will conduct a multi-centre observational trial to investigate the relationship between patient reported outcome measures and preoperative frailty. We aim to recruit approximately two-hundred patients with operable, potentially curative colorectal cancer. Eligible patients will be identified at three hospital sites. QoL and functional ability (measured using EORTC QLQ-C30 and WHO-DAS 2.0 respectively) will be recorded at the pre-operative assessment clinic, and at 6 and 12 weeks postoperatively. Frailty scores including the Edmonton Frail Scale (EFS) and Rockwood clinical frailty scale (CFS) will be calculated both preoperatively, and at 12 weeks post-operatively. Secondary outcome measures including post-operative morbidity and mortality will be measured using Clavien Dindo classification and 90-day mortality. DISCUSSION: This observational feasibility study seeks to define the prevalence of frailty in older (> 65 years) colorectal cancer patients and understand how frailty impacts on patient reported outcome measures. This information will help to inform larger studies relating to treatment decision algorithms and promote shared decision making in this population.

Drain vs. no drain in primary thyroid and parathyroid surgery.

The need for drainage after primary thyroid or parathyroid surgery was evaluated in a prospective study in which 100 consecutive patients were randomly allocated to drainage or no drainage. Seroma developed in the wound in seven of the 50 patients without drainage and in two of the 50 with drainage. There were no residual effects of the seromas, which resolved spontaneously. The incidence of wound complication was unrelated to the surgeon's opinion on the need for drainage. The study provided no statistical report for routine use of drains in primary thyroid or parathyroid surgery.

Choledochoduodenal fistula: a rare complication of duodenal ulcer. Case report.

In a 29-year-old man with pyloric obstruction, plain abdominal radiography showed gas in the biliary tree. Gastroscopy revealed severe duodenal stenosis with a large posterior ulcer, and barium from a test meal passed into the common bile duct. Ten days after truncal vagotomy and gastrojejunostomy, signs of ascending cholangitis appeared. Following antibiotic treatment and cholecystectomy the patient recovered.

Spontaneous rupture of a solitary nonparasitic cyst of the liver. Case report.

A case of spontaneous rupture of a solitary nonparasitic liver cyst is described. This rare condition was detected in a 36-year-old woman who underwent cholecystectomy and cyst excision 3 days after appendectomy. The preoperative diagnosis, including the role of HIDA scan (Hydroxyiminodiacetic acid) is discussed.

Intraaortic balloon tamponade during hemorrhagic shock in sheep.

Two groups (n = 10 in each) of adult sheep were exposed to hemorrhagic shock resulting in mean arterial pressure (MAP) below 25 mmHg for 10 min. Following that, group A received crystalloids (8% of body wt) during one hr together with supraceliac intraaortic balloon tamponade during the first 30 min, while group B (controls) received crystalloids only. The central circulation was rapidly restored in group A, as indicated by increased MAP and increased systemic vascular resistance (SVR). After deflation of the balloon MAP dropped to the same value as in the control group, while cardiac index increased gradually with volume replacement and was significantly higher at the end of the resuscitation period (60 min) than in the control group (P less than 0.05). Despite a more rapid restoration of central hemodynamics in group A, lactic acidosis was more severe, acute renal failure and neurological complications more frequent, and mortality higher than in the control group. It was concluded that continuous supraceliac aortic occlusion for 30 min had deleterious effects on organs dependent on aortic blood flow distal to the aortic tamponade and may contribute to the development of multiple organ failure after resuscitation from hemorrhagic shock. Further studies are needed to evaluate the effects of intermittent intraaortic balloon tamponade in hemorrhagic shock.

Splenic implants: evaluation with radionuclide methods.

The viability of omental splenic implants placed in 16 patients who had undergone splenectomy was assessed with 37 technetium-99m tin colloid studies and five studies with Tc-99m-labeled denatured red blood cells (RBCs). Indications for splenectomy included trauma in eight patients, schistosomal (Bilharzial) portal hypertension in six, splenic artery aneurysm in one, and Wiskott-Aldrich syndrome in one. Studies were done within the 1st month and at various intervals up to 13 months after surgery. Implants in five of eight trauma patients were seen during the 1st month, and implants in seven of seven were seen after 6 months (one patient could not be followed up). Three of six implants in cases of portal hypertension were seen in the 1st month and four of four at 6 months (two patients were not followed up). In two of the five studies with denatured RBCs, Tc-99m tin colloid study was also done 48 hours later; in these cases denatured RBCs were more successful in showing the implants. The authors conclude that radioisotopic procedures are valuable in following up the viability of splenic implants. The "take" of splenic implants in patients with schistosomiasis is equally successful to that in trauma patients.

Ancient neurilemmoma: a pitfall in the cytologic diagnosis of soft-tissue tumors.

A case of ancient neurilemmoma (Schwannoma) is presented that, owing to a severe cell pleomorphism, was falsely interpreted as a malignant spindle-cell sarcoma by fine-needle aspiration cytology. Cytological features of the tumor are given together with its histopathology and electron microscopy findings. The usefulness of electron microscopy on material obtained by fine-needle aspiration biopsies in the diagnosis of soft-tissue tumors is discussed.

Popliteal artery injury in Kuwait.

While there is an abundant literature on popliteal artery injury secondary to penetrating trauma, few reports deal with popliteal artery injury caused by severe blunt trauma with or without fracture. Eight cases of popliteal artery injury are described. Seven of the patients had sustained blunt trauma, usually resulting also in damage to bone and soft tissues. The popliteal vein was involved in five of the injuries. The time lag between causal trauma and vascular repair averaged 25 hours. Delay was due mainly to failure to consult the vascular surgeon at an early stage. Leg amputation was necessary in two cases. Two patients died. The importance of early recognition of the vascular injury and appropriate surgical measures was illustrated in this small series of patients from a developing Middle Eastern country. Adequate fasciotomy, venous repair, use of intraoperative Doppler and repeated postoperative débridement are discussed in connection with management.