Conservative management of diffuse cavernous haemangioma of the sigmoid and rectum.

Diffuse cavernous haemangioma is a rare disease of the rectum. It usually presents with a history of rectal bleeding in children and young adults. When conservative methods fail to control bleeding, traditionally resection is recommended. A 50-year-old man presented with per rectal bleeding and was diagnosed with diffuse cavernous haemangioma of the sigmoid and rectum extending up to 40 cm in the left colon through endoscopy, magnetic resonance imaging and computed tomography. The diagnosis was confirmed by biopsy. This patient was successful managed conservatively with tranexamic acid as needed, avoiding the need for resection.

Accuracy of prediction equations for calculating resting energy expenditure in morbidly obese patients.

INTRODUCTION: The accuracy of prediction equations for estimating resting energy expenditure (REE) in morbidly obese patients is unclear. The aim of this study was to compare the REE measured using bedside indirect calorimetry with commonly used prediction equations. METHODS: A total of 31 morbidly obese patients were studied. Pre-operative REE was measured with indirect calorimetry and compared with estimated REE using the Harris-Benedict and Schofield equations. All patients subsequently underwent a Roux-en-Y gastric bypass and measurements were repeated at six weeks and three months following surgery. RESULTS: The mean age of the patients was 47 years. The mean pre-operative body mass index was 46 kg/m(2). The mean REE measured using indirect calorimetry was 1,980 kcal/day. The estimated REE using the Harris-Benedict and Schofield formulae was 2,195 and 2,129 kcal/day respectively. The equations overestimated REE by 10% and 7%. Body weight and body mass index reduced significantly following Roux-en-Y gastric bypass. There was no significant change in measured REE over the three-month period. After weight loss the difference between the estimated and measured REE reduced to 1-3%. CONCLUSIONS: Prediction equations overestimate REE in morbidly obese patients. Their accuracy improved after surgery induced weight loss, confirming their validity for the normal weight population. Indirect calorimetry should be used in morbid obesity.

Thrombo-prophylaxis in colorectal surgery: a National Questionnaire Survey of the members of the Association of Coloproctology of Great Britain and Ireland.

AIM: Available guidelines from the National Institute for Health and Clinical Excellence (NICE) and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommend combined (medical + mechanical) thrombo- prophylaxis. A Cochrane Library review recommends self-administered low-molecular-weight heparin (LMWH) for 2-3 weeks following surgery. In the light of the recent guidelines from the ACPGBI and NICE, we undertook a National Questionnaire Survey to assess current thrombo-prophylaxis practice among colorectal surgeons in the UK. METHOD: A 10-item questionnaire was designed to enquire into the current management strategy of postoperative thrombo-prophylaxis. The postal questionnaire survey was sent to all 490 active consultant members of the ACPGBI. RESULTS: Of the 490 questionnaires sent, 259 (52.8%) were returned fully completed. Among these, all (100%) respondents reported the routine use of thrombo-prophylaxis, with 243 (93.8%) following departmental guidelines. Combined medical and mechanical prophylaxis was used by 247 (95.40%) respondents. A small number - 12 (4.6%) - used medical prophylaxis only. LMWH was the preferred medical-prophylactic agent of 243 (93.8%) repondents. The majority, 176 (68%), started thrombo-prophylaxis on admission and stopped it at discharge. Seventy-one (27.4%) respondents recommended thrombo-prophylaxis after hospital discharge for an average duration of 4-6 weeks, preferring graduated compression stockings followed by LMWH. CONCLUSION: The National Questionnaire Survey on thrombo-prophylaxis demonstrated a high degree of concordance with the available guidelines, except for thrombo-prophylaxis to be continued postoperatively for a period of 28 days/4 weeks.

Temporary gastric neuromodulation for intractable nausea and vomiting.

INTRODUCTION: Gastric neuromodulation (GNM) has been advocated for the treatment of drug refractory gastroparesis or persistent nausea and vomiting in the absence of a mechanical bowel obstruction. There is, however, little in the way of objective data to support its use, particularly with regards to its effects on gastric emptying. METHODS: Six patients (male-to-female ratio: 4:2, mean age: 49 years, range: 44-57 years) underwent the GNM between April and August 2010. Three patients had confirmed slow gastrointestinal transit. Aetiology included previous gastric surgery in two, diabetes in one and idiopathic nausea and vomiting in three patients. GNM pacing wires were placed endoscopically and left in situ for seven days. Patients underwent gastric scintigraphy before and 24 hours after the commencement of GNM. Total gastroparesis symptom scores (TSS), weekly vomiting frequency scores (VFS), health-related quality of life (using the SF-12(®) questionnaire), gastric emptying, nutritional status and weight were compared before and after GNM. RESULTS: TSS improved after GNM in comparison with baseline data. VFS improved in three of four symptomatic patients. The SF-12(®) physical composite score improved in four patients (27.5 vs 34.3) and the mental composite score improved in five patients (34.9 vs 35.9). All patients reported an improvement in oral intake. A significant weight gain (mean: 1kg, range: 0.3-2.4kg) was observed over seven days. Gastric emptying half-time improved in four patients. CONCLUSIONS: GNM improved upper gastrointestinal symptoms, quality of life and nutritional status in patients with intractable nausea and vomiting. GNM merits further investigation.

Evidence-based review of enhancing postoperative recovery after breast surgery.

BACKGROUND: The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery. METHODS: Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS. RESULTS: Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies. CONCLUSION: This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.

Sacral neuromodulation for the treatment of faecal incontinence in a patient with organophosphate poisoning.

Faecal incontinence is a debilitating condition. Sacral neuromodulation may have a role in the treatment of faecal incontinence. We report a case of faecal incontinence secondary to chronic organophosphate poisoning, which was successfully treated with sacral neuromodulation. The patient's faecal incontinence and quality of life improved significantly.