Anemia to Median Nerve Palsy.

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

Looking beyond the surface: Muir Torre syndrome.

Muir-Torre Syndrome (MTS) is associated with multiple visceral malignancies. Initial presentation may be a benign skin tumor mimicking a sebaceous cyst. This case report highlights the importance of early diagnosis, genetic testing, and multidisciplinary screening. A 67-year-old man was diagnosed with MTS following excision of a skin lesion (sebaceoma). He was declined both screening colonoscopy and genetic testing. Subsequently, advanced colon cancer was found following presentation with iron deficiency anemia, which ultimately led to palliation despite successful surgery. MTS can present insidiously with skin lesions clinically diagnosed as sebaceous cysts. Once MTS is suspected on histology, genetic testing and screening for MTS-related cancers is warranted. Better understanding of the genetic variants for MTS can aid in earlier diagnosis thus not dismissing the need for screening for MTS-related cancers.

Predicting length of stay for acute medical admissions in New Zealand: the MALICE score.

Predicting length of stay (LoS) in hospital can help guide patient placement, facilitate rapid discharge and aid identification of patients at risk of prolonged stay, in whom early multidisciplinary intervention is warranted. We aimed to pilot the applicability of a modified decision aid (MALICE score) for predicting LoS for acute medical admissions at a New Zealand hospital. A prospective pilot study of 220 acute general medical admissions was performed. Clinical records were reviewed and MALICE scores were calculated for each patient and compared with LoS data using the Kruskal-Wallis H test. A statistically significant increase in LoS was seen with rising MALICE scores (H value 26.85, P < 0.001). MALICE scoring could be employed to guide patient placement and identify patients at risk of prolonged stays, though further study of bedside feasibility and applicability is required.

A further look into obtaining informed consent for medical students.

Nil.

Improving prescribing of extended prophylaxis for venous thromboembolism at discharge in patients who underwent surgery for colorectal cancer.

AIMS/BACKGROUND: Prophylaxis at discharge is important in mitigating venous thromboembolism events from colorectal cancer and major abdominopelvic surgery, both of which are risk factors for venous thromboembolism. Foundation doctors frequently rotate between departments, and so rely on departmental induction and/or handing down of knowledge to prescribe extended venous thromboembolism prophylaxis upon discharge. METHODS: A retrospective audit of all patients who underwent surgery for colorectal cancer at The County Hospital, Hereford, between 1 August 2018 and 31 August 2019, was undertaken to assess departmental compliance with guidance from the National Institute for Health and Care Excellence. RESULTS: A total of 181 patients underwent elective surgery and 29 patients had emergency surgery. The initial audit revealed a cyclical 4-monthly decline that coincided with foundation doctors' rotations. Six multidisciplinary interventions were implemented. Reaudit demonstrated 100% compliance with prescribing of extended venous thromboembolism prophylaxis at discharge. No venous thromboembolism events 30 days post operation were noted. CONCLUSIONS: A multidisciplinary approach involving educating health professionals about the importance of extended venous thromboembolis prophylaxis in patients who have undergone surgery for colorectal cancer can be effective in improving compliance with prescribing practices at discharge.

Leukaemia-in-ano.

Fistula-in-ano is a very common surgical condition, caused by anal cryptoglandular inflammation. Most cases are idiopathic. Other causes such as Crohn's disease, trauma and malignancy are well known. Management of fistula-in-ano is largely surgical, especially if the patient is symptomatic. The goal of surgical therapy is sepsis drainage, delineate anatomy and eradicate the fistula while preserving faecal continence. Establishing the aetiology is also crucial as often a combination of specialist medical therapy is required, for example, in Crohn's disease. We report an extremely unusual case of fistula-in-ano on an elderly man with chronic lymphocytic leukaemia (CLL). Histology from the fistula track demonstrated CLL infiltration. This case, not previously reported on PubMed search, illustrates a good example of joint specialist medical (a haematologist) and surgical effort in successfully treating this symptomatic fistula-in-ano.

"Fungating" tumour? No, it's bacterial!

A fit and healthy 26-year-old woman presented to the general surgical team with epigastric pain and weight loss of 2 stones over 6 months. She has also a positive family history of ulcerative colitis. As her oesophagogastroduodenoscopy and colonoscopy were normal, a contrasted CT was requested, and it detected an inflammatory mass with fat streaking around her transverse colon. An intrauterine contraceptive device (IUCD) was noted. In light of the CT findings, she underwent a diagnostic laparoscopy. As the inflammatory mass was not separable from the transverse colon, a segmental transverse colectomy was proceeded. The histology revealed multiple actinomycosis abscesses in the mesentery. Subsequently, we learnt that her IUCD had been in situ for the last 7 years, and the source of actinomycosis abscesses is likely from her IUCD. The patient was recommended to have the coil removed and commenced on a 6 months course of amoxicillin.

Buried coin in the gastric mucosa.

A 29-year-old man presented to the Accident and Emergency department with abdominal cramping following ingestion of a 50 p coin 2½ weeks prior to presentation. He had not observed it pass in his stools. An abdominal radiograph confirmed the presence of the 50 p coin in his stomach. Subsequently, he had an oesophagogastroduodenoscopy (OGD) performed with a failure to visualise the coin. 1½ weeks later, he returned to the department as he was still unable to observe its passing in his stools. A repeated abdominal radiograph and a CT of the abdomen and pelvis revealed that the coin was still in his stomach. A second OGD was performed once again with a failure to visualise the coin. It appeared that the coin had migrated into his gastric mucosa.

Avoiding emergency stoma surgery with the use of sugar.

George Theofanis, Mahmud Saedon, Soo Hua Kho, Francesk Mulita, Stylianos Germanos and Edmund Leung discuss the use of sugar as an aid to reducing a stomal prolapse.

Nontraumatic Emergency Laparotomy: Surgical Principles Similar to Trauma Need to Be Adopted?

OBJECTIVES: In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival. METHODS: All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis. RESULTS: In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality. CONCLUSIONS: The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia.

Colonic Perforation: A Medical Complication.

Hypothyroidism is a common comorbidity that on acute presentation is often overlooked. It can be an easily managed condition; however non-compliance can have severe consequences. In the presented case it was requirement for emergency surgery that resulted in stoma formation. This case is a first example of the need to include patient's decision making process with regards to medication adherence in the setting of chronic disease.

Internal Herniation Through Foramen of Winslow: A Diagnosis Not to Be Missed.

INTRODUCTION: Hernias through the foramen of Winslow are extremely rare, accounting for 0.1% of all abdominal hernias. Delayed diagnosis is often observed, resulting in bowel strangulation and high mortality. METHOD: We present a case of a patient with strangulated ileum herniated through the foramen of Winslow. Recent literature review was undertaken on "PubMed" as a search platform using the keywords "foramen of Winslow" and "hernia". CASE SUMMARY: A 66-year-old man presented acutely with severe epigastric pain and vomiting. An emergency computed tomography scan revealed a loop of ileum in the lesser sac. At emergency laparotomy, a herniated loop of ileum that had become strangulated at its entry to the lesser sac via the foramen of Winslow was confirmed. The loop of ileum was reduced but was nonviable, which had to be resected with a primary anastomosis. The patient's postoperative recovery was uneventful. CONCLUSION: Herniation through the foramen of Winslow is a difficult diagnosis and must not be missed. Early cross-sectional imaging and surgical intervention are advised in order to reduce morbidity.

The Two-Week Referral System for colorectal cancer--not fit for purpose.

PURPOSE: The UK government target expects all suspected colorectal cancer (CRC) patients to be seen within the Two-Week Referral (TWR) system made by general practitioners. These guidelines originally derived from only level 5 evidence. However, this has significant impact on the workload for colorectal surgeons. The aim of the study is to investigate the effectiveness of this colorectal service and whether the referral criteria are predictive of CRC. METHODS: A retrospective study of all patients referred under the TWR guidance in 2010 was assessed. The first 573 TWRs were piloted for analysis. Clinical information from each patient was collected regarding TWR criteria and additional colorectal symptoms or risk factors. Multiple regression analysis was performed to determine which symptoms independently correlated with CRC. RESULTS: One hundred twenty-six CRCs were diagnosed via all methods of referral in 2010. There were 940 patients referred under the TWR guidelines in that year, when 50 CRC patients were identified. Amongst the 573 patients, 32 CRCs were diagnosed. Multiple regression analysis revealed tenesmus to be independently associated with CRC (p = 0.003, Pearson's r = 0.09185). None of the individual TWR criteria confidently predicted CRC. CONCLUSION: Our preliminary results suggest that the current TWR guidelines cannot effectively predict CRC. There is an urgent need for an evidence-based approach to referral criteria for suspected CRC.

Preliminary results of sacral transcutaneous electrical nerve stimulation for fecal incontinence.

BACKGROUND: Fecal incontinence is a common debilitating condition. OBJECTIVE: The aim of this study is to investigate the feasibility of sacral transcutaneous electrical nerve stimulation as an alternative treatment modality for fecal incontinence. DESIGN: All consecutive patients who presented with fecal incontinence to the senior author's clinic were prospectively recruited between June 2009 and September 2010. The severity of their fecal incontinence was assessed by the Wexner and Vaizey scores and anal physiology. MAIN OUTCOME MEASURES: Any improvement following a period of sacral transcutaneous electrical nerve stimulation treatment was determined by repeating the scores. In addition, patient satisfaction with the procedure was assessed by using a patient impression score. RESULTS: Twenty female patients with a median age of 57.5 years (range, 30-86) were evaluated. The median follow-up was 10 months (range, 5-12 months). Two patients did not record a change in their Vaizey score. The overall mean Wexner score was 7.9 ± 4.2 before in comparison with 4.0 ± 3.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 2.2-5.7, SE = 0.832). The overall mean Vaizey score was 12.7 ± 5.7 before in comparison with 5.8 ± 5.6 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 4.5-9.4, SE = 1.162). The pretreatment patient impression score was set at a mean of 1 ± 0 in comparison with 2.8 ± 1.1 after sacral transcutaneous electrical nerve stimulation treatment (p < 0.0001, CI = 1.2-2.3, SE = 0.25). CONCLUSION: The preliminary results suggest sacral transcutaneous electrical nerve stimulation is a promising noninvasive alternative to existing modalities in the treatment of idiopathic fecal incontinence.

Isolated unilateral tongue oedema: the adverse effect of Angiotensin converting enzyme inhibitors.

Angiotensin converting enzyme inhibitors (ACEI) are widely used to treat benign hypertension. These drugs are generally well tolerated. Serious side effects such as angio-oedema are very rare. The authors report a 64-year-old Caucasian woman with a history of liver transplant on Mammalian Target Of Rapamycin (mTOR) inhibitor, who attended Emergency department with angio-oedema only on the left side of her tongue. Her airway was patent and she was haemodynamically stable. Trauma was denied. Her physician had 2 days earlier commenced her on Lisinopril for newly diagnosed benign hypertension. Intravenous steroids and anti-histamine were immediately administered. A good response of oedema subsidence was noted. In general, angio-oedema can present in a spectrum of severity. Precipitating factors are often difficult to pre-determine and avoid. Early recognition of risk factors for and diagnosis of angio-oedema can often be life-saving.

Risk-adjusted scoring systems can predict surgeons' performance in colorectal surgery.

INTRODUCTION: the physiological & Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) was derived from a heterogeneous general population and has been used successfully as an audit tool to provide risk-adjusted operative mortality rate. The aim of this study was to investigate whether risk-adjusted scoring systems can accurately predict outcomes of colorectal operations done by colorectal and non-colorectal surgeons. METHOD: the study was conducted prospectively on 899 consecutive patients who underwent major elective and emergency colorectal procedures over three years between 2002 and 2004 at University Hospital Coventry and Warwickshire. The outcome parameter was defined as 30-day mortality. The observed mortality was then compared to POSSUM-predicted mortality. Hosmer-Lemeshow and Fisher's Exact test were used to assess statistical significance in outcome between non- and coloproctologists. RESULTS: CR-POSSUM was the most accurate predictive model for outcomes of major colorectal operations between surgeons. The overall mortality rate amongst coloproctologists was 7% (5% elective & 13% emergency), whereas the overall mortality was 17% (3% elective & 21% emergency) in non-coloproctologists. CONCLUSION: CR-POSSUM was the better prediction model than POSSUM. Coloproctologists delivered a significantly lower overall mortality, but not in the emergency setting. However, given the few number of elective colorectal resections performed by non-coloproctologists, more cases are required to permit meaningful comparison for the outcomes of major colorectal operations among different surgeons.

Risk-adjusted scoring systems in colorectal surgery.

Consequent to recent advances in surgical techniques and management, survival rate has increased substantially over the last 25 years, particularly in colorectal cancer patients. However, post-operative morbidity and mortality from colorectal cancer vary widely across the country. Therefore, standardised outcome measures are emphasised not only for professional accountability, but also for comparison between treatment units and regions. In a heterogeneous population, the use of crude mortality as an outcome measure for patients undergoing surgery is simply misleading. Meaningful comparisons, however, require accurate risk stratification of patients being analysed before conclusions can be reached regarding the outcomes recorded. Sub-specialised colorectal surgical units usually dedicated to more complex and high-risk operations. The need for accurate risk prediction is necessary in these units as both mortality and morbidity often are tools to justify the practice of high-risk surgery. The Acute Physiology And Chronic Health Evaluation (APACHE) is a system for classifying patients in the intensive care unit. However, APACHE score was considered too complex for general surgical use. The American Society of Anaesthesiologists (ASA) grade has been considered useful as an adjunct to informed consent and for monitoring surgical performance through time. ASA grade is simple but too subjective. The Physiological & Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and its variant Portsmouth POSSUM (P-POSSUM) were devised to predict outcomes in surgical patients in general, taking into account of the variables in the case-mix. POSSUM has two parts, which include assessment of physiological parameters and operative scores. There are 12 physiological parameters and 6 operative measures. The physiological parameters are taken at the time of surgery. Each physiological parameter or operative variable is sub-divided into three or four levels with an exponentially increasing score. However, POSSUM and P-POSSUM over-predict mortality in patients who have had colorectal surgery. Discrepancies in these models have led to the introduction of a specialty-specific POSSUM: the ColoRectal POSSUM (CR-POSSUM). CR-POSSUM only uses six physiological parameters and four operative measures for prediction of mortality. It is much simplified to allow ease of use.