A rare case of segmental small bowel pneumatosis intestinalis: A case report.

INTRODUCTION: Pneumatosis intestinalis is a rare condition affecting 0.03% of the population. It has a myriad of aetiological causes and hence presentation can vary immensely. The management of symptomatic pneumatosis intestinalis in an acute and outpatient setting remains a challenge to both physicians and surgeons. CASE PRESENTATION: We present a case of a 79 year old who presented in a gastroenterology outpatients department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain aggravated by eating and posture. He was found to have signs suggestive of Marfan's syndrome. Computed tomography demonstrated extensive pneumatosis intestinalis of the small bowel. Due to deterioration in symptoms, an exploratory laparotomy was performed demonstrating segmental small bowel pneumatosis intestinalis secondary to a hypermobile mesentery. CONCLUSION: This case highlights the importance of both surgical and gastroenterology expertise in successfully managing symptomatic pneumatosis intestinalis.

Laparoscopic colorectal cancer surgery in obese patients.

AIM: The aim of this study was to assess the oncological and postoperative outcomes of laparoscopic colorectal cancer surgery in obese patients. METHOD: All obese (BMI > 30) patients who underwent laparoscopic colorectal cancer surgery from January 2005 to January 2008 were compared with nonobese patients undergoing similar surgery. We recorded patient demographics, intra-operative details and postoperative morbidity and mortality. RESULTS: Sixty-two obese and 172 nonobese patients underwent laparoscopic colorectal cancer resection. Both groups were well matched for demographic parameters. Overall mean operating times were not significantly different. Conversion to open surgery was more likely in obese patients. In particular, for rectal cancers, the conversion rate was 44% in the obese group compared with 17% in the nonobese group (P < 0.05). Postoperative morbidity was also greater in obese patients (P < 0.05). The duration of hospital stay was similar for laparoscopically completed cases (6 days obese vs 7 days nonobese), but in the obese-converted group it was 14 days (P < 0.05). The resected specimen with respect to length, resection margin and lymph node retrieval was equivalent between obese and nonobese patients. Disease-free survival and overall survival at a median follow up of 2 years were also similar. CONCLUSIONS: Laparoscopic colorectal cancer surgery in obese patients is technically feasible and oncologically safe. Despite greater postoperative morbidity, obese patients benefit from shorter length of stay. However, a higher conversion rate, particularly for rectal cancers, should be anticipated in obese male patients.

Surgical trainees benefit from good consultant working practices: an audit on the effect on training of a new consultant rota.

PURPOSE: To retrospectively assess operative supervision for orthopaedic trainees over an 18 week period when trauma and orthopaedic consultants changed their on call working practice from one week on call to a four day/three day block, during a fortnight period. OUTCOME: The rota changes had important implications on workload and consultant availability to supervise juniors during operation with a positive effect upon training such that trauma surgery supervision rates increased significantly (p<0.001) after the introduction of these new working arrangements. Working life for consultants and ultimately patient care were also felt to improve and consultants' working hours were closer to the European working hours directives.

Split transverse colostomy: an alternative method of defunctioning the distal colon.

Split transverse colostomy is a novel method of defunctioning the distal colon. Herein, we describe the method of this procedure and present early interim results showing that this procedure is safe, relatively complication free and feasible for many pathologies affecting the colon and pelvis, especially in alleviation of symptoms for palliation.

A study comparing split with loop transverse colostomies for defunctioning the left colon.

BACKGROUND: Loop transverse colostomy (LTC) is an established method for defunctioning the distal colon. We recently described an alternative method called split transverse colostomy (STC). METHODS: In this study we retrospectively compared the outcomes of LTC and STC in 49 patients with colorectal malignancy, pelvic tumours and diverticular disease. RESULTS: Patients were assigned without randomisation to undergo LTC (n=25) or STC (n=24). The two groups were similar in terms of age, gender and diagnosis. Postoperative complications were observed in 52.0% of patients in LTC group and in 16.7% of patients in STC group (p<0.05). The most common complication in both groups was stomal prolapse (n=2 and n=10, respectively). There were no intra-operative deaths. CONCLUSIONS: STC is safe, effective and associated with a lower incidence of stomal complications compared with the established procedure for defunctioning the distal colon. We propose that STC should be used to defunction the left colon in locally advanced disease (whether benign or malignant) where closure of the stoma is not envisaged.

Accuracy of computed tomography in the detection of blunt bowel and mesenteric injuries.

BACKGROUND: There are conflicting views on the accuracy of computed tomography (CT) findings in patients with bowel and mesenteric injuries (BMIs) following blunt abdominal trauma. The aim of the present study was to assess the accuracy of the CT report during a trauma call. METHODS: Ninety-eight patients underwent preoperative abdominal spiral CT and subsequent laparotomy following blunt trauma between January 1996 and March 2001 at a level I trauma centre. The immediate results of the scans were reported by the on-call radiology registrar and written in the medical notes by the trauma team leader. Seventy of the 98 preoperative abdominal CT scans were retrieved from the radiology department and reported by two consultant radiologists with a special interest in trauma radiology. RESULTS: The sensitivity and specificity of the 70 expert CT reports were 80 (95 per cent confidence interval (c.i.) 66 to 94) and 78 (95 per cent c.i. 65 to 90) per cent respectively for diagnosing a BMI. The sensitivity and specificity of the immediate CT reports were 93 (95 per cent c.i. 84 to 100) and 71 (95 per cent c.i. 60 to 83) per cent respectively. CONCLUSION: Spiral CT is highly sensitive for detecting a BMI following blunt abdominal trauma. This sensitivity is maintained when the scan is reported by a radiology registrar.

Annular pancreas - a rare cause of gastric obstruction in an 82-year-old patient.

Annular pancreas is an uncommon and rarely reported congenital anomaly and thus is rarely suspected. A case is reported of an 82-year-old patient who presented with a 3-month history of nausea and vomiting associated with weight loss who at laparotomy was found to have an annular pancreas.

Spontaneously arising superficial temporal artery aneurysms: a report of two cases and review of the literature.

The majority of superficial temporal artery (STA) aneurysms are due to trauma and are, in reality, false aneurysms. However, true STA aneurysms are extremely rare. Here, we present two cases of spontaneous superficial temporal artery aneurysms arising without any previous history of trauma.

Mesh erosion into the bladder: a late complication of incisional hernia repair. A case report and review of the literature.

Late complications of mesh repair are commonly due to mesh migration and erosion into neighbouring visceri. We report the first case of a mesh repair of a lower midline laprotomy incisional hernia complicated by erosion of the mesh into the bladder which presented as haematuria.

Oxygen radical-dependent expression of CXC chemokines regulate ischemia/reperfusion-induced leukocyte adhesion in the mouse colon.

Activation and accumulation of leukocytes constitute a rate-limiting step in ischemia/reperfusion (I/R)-induced tissue injury. The signalling mechanisms, however, that regulate leukocyte rolling and adhesion in the colonic microcirculation are not known. The objective of the study was to define the role of CXC chemokines (MIP-2 and KC) in I/R-induced leukocyte-endothelial cell interactions in the mouse colon. In C57/B16 mice, colonic ischemia was induced by clamping the superior mesenteric artery for 30 min and leukocyte rolling and stationary adhesion were examined in venules after 120 and 240 min of reperfusion. I/R provoked a clear-cut increase in leukocyte rolling and adhesion in colonic venules. Both MIP-2 and KC were upregulated at the gene and protein level in the reperfused colon. Immunoneutralization of MIP-2 and KC by monoclonal antibodies reduced reperfusion-induced firm adhesion of leukocytes by 73% and 75%, respectively. Interestingly, combined inhibition of MIP-2 and KC additionally decreased leukocyte rolling by 79%, but did not further reduce the number of firmly adherent leukocytes. To study the role of oxygen free radicals (OFRs) in the regulation of CXC chemokine expression, additional animals were pretreated with the xanthine-oxidase inhibitor allopurinol. In fact, allopurinol treatment reduced the colonic levels of MIP-2 and KC by 62% and 64%, respectively. This study elucidates important interactions between OFRs and chemokines in the I/R-induced leukocyte response in the mouse colon. Moreover, our data demonstrate that CXC chemokines play a fundamental role in colonic I/R and that functional interference with CXC chemokines may protect against pathological inflammation in the colon.

Allopurinol and superoxide dismutase protect against leucocyte-endothelium interactions in a novel model of colonic ischaemia-reperfusion.

BACKGROUND: Leucocyte recruitment is a key feature in ischaemia-reperfusion (I/R)-triggered tissue injury. However, the mechanisms underlying leucocyte-endothelium interactions in the large bowel remain elusive because of a previous lack of models to examine the colonic microcirculation. The aim of this study was to develop and validate a novel method for studying reperfusion-induced leucocyte-endothelium interactions in the colon. METHODS: The superior mesenteric artery was occluded for 30 min in male C57/Bl6 mice and leucocyte responses were analysed in colonic venules after 30-240 min of reperfusion. Analysis of leucocyte rolling and adhesion in colonic venules was made possible by an inverted approach using intravital fluorescence microscopy. RESULTS: Thirty minutes of ischaemia and 120 min of reperfusion induced the strongest and most reproducible increase in leucocyte rolling and adhesion. This was associated with a significant increase in colonic levels of malondialdehyde (MDA). Administration of allopurinol and superoxide dismutase reduced I/R-induced leucocyte responses in a dose-dependent manner. Pretreatment with allopurinol attenuated the tissue content MDA in the colon by more than 60 per cent. CONCLUSION: A new method for examining I/R-induced leucocyte responses in the colonic microcirculation is described. Oxygen free radicals play an important role in triggering leucocyte rolling and adhesion in colonic venules.

Tuberculosis of the pancreas diagnosed with needle aspiration.

Tuberculosis of the pancreas is very rare and can present with many signs and symptoms, including obstructive jaundice, weight loss and a mass in the head of the pancreas. Hence the diagnosis of pancreatic tuberculosis remains a challenge and a high index of suspicion is required. If a tumour is suspected then an ultrasound- or CT-guided fine needle aspiration should be performed. Even if the initial microbiological results are negative, using conventional techniques, PCR can yield more rapid results and avoid an unnecessary laparotomy.

Delayed complications following Tenckhoff catheter removal.

BACKGROUND: Tenckhoff catheter placement is well established to facilitate continuous ambulatory peritoneal dialysis (CAPD) in the treatment of end-stage renal failure. Complications of these catheters while in situ are well documented. However, little information is available concerning post-removal complications. Many centres, including our own remove these catheters by traction resulting in retained cuffs, rather than by formal dissection. We have evaluated the outcome of such removal over a 2-year period. METHODS: Sixty-two patients underwent Tenckhoff catheter removal by traction over a 2-year period at our unit. Patients were evaluated retrospectively using case notes and operation records. RESULTS: The catheters were sited for a mean of 23 months and were most commonly removed because of persistent peritonitis (48.4%). Sixty-one per cent of all patients had experienced at least one episode of CAPD peritonitis while the catheter was in situ, but this did not correlate with those who developed local sepsis. Fifteen patients (24.2%) subsequently developed local infective complications after a mean of 5.7 months (range 1-17 months). The subcutaneous cuff was involved in all cases and the peritoneal cuff was involved in six cases. Thirty patients were identified as being immunosuppressed, but this was not a risk factor in the development of retained cuff infections. CONCLUSIONS: There is a significant risk of local sepsis with retained cuffs resulting from removal by traction and our data suggests that these catheters should be removed by dissection and excision of both cuffs.