A selective approach to restorative proctocolectomy without ileostomy: a single centre experience.

OBJECTIVE: A single surgeon series on complications and functional outcomes following restorative proctocolectomy (RPC) is presented. METHOD: An ethically-approved database was used to collect data on all patients undergoing RPC at a single institution. Patient demographics, operative details, complications and functional outcomes were assessed. The impact of ileostomy omission on outcomes was also assessed. RESULTS: Two hundred patients undergoing RPC between 1987 and 2006 were included. There were 122 (61.0%) males and the mean age at surgery was 37.6 years. A J pouch was constructed in 199 (99.5%) patients and an ileostomy omitted in 160 (80.0%). Since adopting a selective policy after the 36th consecutive patient in the series, only 9 (5.5%) patients have had an ileostomy constructed at the time of pouch construction. Complications occurred in 112 (56.3%) patients, with anastomotic stricture (20.6%) and pouchitis (28.6%) being the most common. Anastomotic stricture was more common in those patients receiving an ileostomy (43.6%vs 15.0%, P < 0.001), as were pouch-cutaneous fistulae (5.1%vs 0.6%, P = 0.039) and pelvic sepsis (15.4%vs 5.0%, P = 0.023). Functional outcomes were good, with median 24-h stool frequency of five motions at 1 year. There was increased urgency to defaecate which in part may be due to a significant decline in the use of antidiarrhoeal medication during follow up. CONCLUSIONS: Selective omission of a covering ileostomy in most cases can produce good results following RPC with no increase in the risk of septic complications or pouch failure, and a decreased risk of anastomotic stricture, with maintenance of good function in the majority.

Flexible sigmoidoscopy performed by nurses.

Flexible sigmoidoscopy by nurses has rapidly become a widely accepted technique for distal colonic investigation. This review explores the issues of training and application of nurse performed flexible sigmoidoscopy, including the limitations, complications and cost issues.

Transverse verses midline incisions for abdominal surgery.

BACKGROUND: The choice of surgical incision in the abdomen is determined by access for surgery. It has been suggested that utilising a transverse or oblique rather than a midline incision may influence other parameters such as recovery and complication rates. However, there is little consensus in the literature as to whether a particular incision confers any advantage. OBJECTIVES: To determine whether a midline incision or a transverse incision (including oblique incision) confers any recovery advantage to the patient. SEARCH STRATEGY: Search terms included randomised trials containing combinations of the following: 'abdominal', 'incisions', 'horizontal', 'transverse', 'vertical', 'midline', and 'laparotomy'. SELECTION CRITERIA: All prospective randomised trials comparing midline with transverse incisions for abdominal surgery were included. Caesarian sections were excluded. DATA COLLECTION AND ANALYSIS: Two review authors assessed the methodological quality of potentially eligible trials and independently extracted data from the included trials. A wide range of outcome measures was considered. MAIN RESULTS: Due to differences in the method of assessment, the variability of data and the heterogeneity of the participant groups it was difficult to pool some of the outcome data. Despite these limitations, and potentially significant biases related to methodological quality, there was evidence to suggest that a transverse or oblique incision may be less painful and have less impact on pulmonary function than a midline incision, particularly in the early postoperative period. However, there was no difference seen in early or late postoperative complications between a transverse or oblique and a midline incision and recovery times were similar. AUTHORS' CONCLUSIONS: Both analgesia use and pulmonary compromise may be reduced with a transverse or oblique incision but this does not seem to be significant clinically as complication rates and recovery times are the same as with midline incision. The methodological and clinical diversity and the potential for bias in the included studies also mean that the results in favour of a transverse or oblique incision, particularly with regard to analgesic use, should be treated with caution. The optimal incision for abdominal surgery still remains the preference of the surgeon.

The future of coloproctology in the UK: the trainees view.

INTRODUCTION: Major changes are imminent in the mode of surgical training and the manner both ''general'' and ''specialist'' surgeons provide services. This is the first interactive survey of UK Coloproctology trainees. METHODS: At the 2004 DUKES Club (colorectal trainees) meeting an interactive digital-media voting system enabled blinded assessment of members regarding training and organisational issues in Coloproctology. RESULTS: 78% of trainees intended to be colorectal specialists. 92% thought a specialist qualification necessary, 90% believed it should be administered at the time of certificate of completion of training (CCT). Overall, 40%, 40% and 20% would pay 1000 <, 1000-3000 pounds and > 5000 pounds respectively per year for adequate training. Over 80% thought low anterior resection, APER, major lower GI-bleeding, pelvic floor, IBD and rectal cancer surgery should only be performed by specialists, and many thought colonic cancer surgery (46%), diverticular surgery (52%), and perianal sepsis (38%) management was a specialist necessity. CONCLUSION: UK Colorectal trainees believe a specialist exam necessary, colorectal specialists should treat a defined group of conditions/cases and would pay for adequate training.

Nurse endoscopy in a district general hospital.

INTRODUCTION: This study describes the first full year of independent practice by a newly appointed nurse endoscopist in a district general hospital. PATIENTS AND METHODS: Patients underwent either 'one stop' flexible sigmoidoscopy and barium enema or flexible sigmoidoscopy alone. Barium enema results, video photography, clinical follow-up, and histology were used to validate the results of the flexible sigmoidoscopy. One stop clinic: 161 endoscopies were performed, with 104 female patients (65%), and a mean age of 64 years. There was one failed endoscopy due to poor bowel preparation. Abnormalities were identified in 84% of endoscopies. Flexible sigmoidoscopy detected abnormalities not seen on the barium enema in 28 cases, all of which were polyps (18%). Barium enema identified one abnormality within reach of the flexible sigmoidoscope not identified at endoscopy (small polyp in sigmoid; 1%). Elective flexible sigmoidoscopy list: 121 endoscopies were performed, with 65 female patients (54%), and a mean age of 59 years. There were two failed endoscopy procedures, both attributed to poor bowel preparation. Two-thirds of patients had an abnormality on investigation. There were no complications in either group of patients. CONCLUSIONS: The nurse-led endoscopy service has been successfully initiated with a high completion rate for flexible sigmoidoscopies. All significant conditions were identified with 99% sensitivity. Nurse endoscopy is a safe, useful and practical procedure in the setting of this district general hospital.

Metastatic adenocarcinoma arising from a small bowel duplication cyst.

A case report of adenocarcinoma arising from a small bowel mesenteric cyst is presented. A discussion and review of the relevant literature then follows.

Students sitting medical finals--ready to be house officers?

An initial survey of students approaching qualification and the preregistration house officer year revealed anxiety about competence in several important clinical skills. A questionnaire study was then undertaken to assess, first, the extent to which students had attained the skills required for the preregistration year and, second, the amount of training in these skills provided during the preregistration year. 122 medical students taking their final examinations were asked about training and practice in eight core clinical skills, and 84 graduates from the same school, approaching the end of their preregistration year, were asked about postgraduate training in these skills. The response rate of each group was 100%. Of the eight skills studied, most had been performed few times by the students at qualification. Less than half the current preregistration house officers could recall training being given in any of the skills studied. There were no significant differences in house-officer training between teaching hospitals and district general hospitals. Regarding needlestick injuries, nearly two-thirds of preregistration house officers were unable to recall any training at either undergraduate or postgraduate level. These results suggest that training in clinical skills can be improved. Training is already changing with use of clinical skills laboratories and logbooks. We also recommend mandatory needlestick training both in undergraduate programmes and in induction courses for preregistration house officers.

Squamous cell carcinoma of the colon in an asbestos worker.

We report a case of squamous cell carcinoma of the colon in an asbestos worker. We speculate whether the asbestos exposure could have been causative and review the literature.