Transanal endoscopic microsurgery: a new technique for completion proctectomy.

AIM: Following subtotal colectomy, the retained rectal stump is a potential source of morbidity. Although restorative ileal pouch-anal anastomosis is the gold standard for ulcerative colitis, up to 14% of patients will opt for a permanent ileostomy and undergo completion proctectomy, traditionally by an abdomino-perineal approach, which itself carries significant morbidity. We describe a new technique of perineal proctectomy using transanal endoscopic microsurgery (TEMS) equipment. To our knowledge, this technique has not previously been described in the literature. METHOD: Twelve patients, mean (SD) age 66 (±13) years, underwent TEMS proctectomy, performed by a single surgeon between January 2007 and October 2011. Excision began with an intersphincteric dissection following which the TEMS (WOLF) proctoscope was inserted and close rectal dissection was performed, entering the peritoneal cavity (if the top of the stump was intraperitoneal). Following perineal extraction of the specimen, the external sphincter and skin were closed with an absorbable suture. RESULTS: Nine patients had inflammatory bowel disease, two had neoplasia and one had intractable radiation proctitis. The mean (SD) rectal stump length was 17.8 (±6.1) cm and the peritoneal cavity was entered in nine patients, with no small-bowel injury. The median postoperative hospital stay was 5.5 days. In four patients there was delayed healing of the perineal wound. There was no perioperative mortality. CONCLUSION: TEMS perineal proctectomy is a novel, but safe, technique that may avoid the need for a traditional abdominoperineal approach in selected patients.

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series.

INTRODUCTION: The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar. CASES: Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars. CONCLUSIONS: Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.

Intra-operative oxygen delivery in infusion volume-optimized patients undergoing laparoscopic colorectal surgery within an enhanced recovery programme: the effect of different analgesic modalities.

AIM: Patients undergoing major open surgery who have an indexed oxygen delivery (DO(2) I) > 600 ml/min/m(2) have been shown to have a lower incidence of morbidity and mortality compared with those whose DO(2) I is below this level. Laparoscopy and Trendelenburg positioning cause a reduction in DO(2) I. We aimed to quantify the effect of the type of analgesia on DO(2) I and to correlate the DO(2) I achieved with the incidence of anastomotic leakage in patients undergoing laparoscopic surgery. METHOD: Following ethical approval, patients were randomized to receive spinal anaesthesia (Group S), epidural analgesia (Group E) or intravenous morphine (Group P) followed by postoperative patient-controlled analgesia (PCA). In addition to standard monitoring, oesophageal Doppler monitoring of the stroke volume allowed directed intravenous fluid therapy. The mean DO(2) I was compared with the anastomotic leakage rate. RESULTS: Seventy-five patients were recruited (Group S, 27; Group E, 23; Group P, 25). The mean (range) DO(2) I for all patients was 490 (230-750) ml/min/m(2) . The analgesic modality had no effect on DO(2) I. Of the 18 patients with a DO(2) I of < 400 ml/min/m(2) , four (22%) developed anastomotic leakage compared with one (%) of the 57 patients with a DO(2) I of > 400 ml/min/m(2) (P = 0.01). CONCLUSION: The analgesic modality used had no effect on the DO(2) I achieved. Anastomotic leakage was significantly higher in patients with a DO(2) I of < 400 ml/min/m(2) . A further study assessing the outcome after raising the DO(2) I with inotropes is required.

Optimizing patient outcomes in laparoscopic surgery.

There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient's outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. 1 Analgesia - The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2 Individualised goal directed therapy - It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach.

Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery.

BACKGROUND: Epidural analgesia is considered fundamental in enhanced recovery protocols (ERPs). However, its value in laparoscopic colorectal surgery is unclear. The aim of this study was to examine the effects of different analgesic regimens on outcomes following laparoscopic colorectal surgery in fluid-optimized patients treated within an ERP. METHODS: Ninety-nine patients were randomized to receive epidural, spinal or patient-controlled (PCA) analgesia. The primary endpoints were time until medically fit for discharge and length of hospital stay. Secondary endpoints included return of bowel function, pain scores, and changes in pulmonary function and quality of life. RESULTS: Ninety-one patients completed the study. The median length of hospital stay was 3.7 days following epidural analgesia, significantly longer than that of 2.7 and 2.8 days for spinal analgesia and PCA respectively (P = 0.002 and P < 0.001). There was also a slower return of bowel function with epidural analgesia than with spinal analgesia and PCA. Epidural analgesia did not offer better preservation of pulmonary function or quality of life, although pain scores were higher in the PCA group in the early postoperative period. CONCLUSION: Many of the outcomes in the epidural analgesia group were significantly worse than those in the spinal analgesia and PCA groups, suggesting that either of these two modalities could replace epidural analgesia.

A systematic review of postoperative analgesia following laparoscopic colorectal surgery.

OBJECTIVE: The use of epidural analgesia is considered fundamental in Enhanced Recovery Protocols. However its value in the perioperative management of laparoscopic colorectal surgical patients is unclear and analgesic regimens vary. The aim of this systematic review was to examine the effects of various analgesic regimes on outcomes following laparoscopic colectomy. METHOD: A systematic review of studies assessing analgesic regimes following laparoscopic colorectal resection was performed. The primary outcome of interest was length of hospital stay whilst the secondary outcomes included pain, time to tolerate a normal diet, return of bowel function and postoperative complications. RESULTS: Eight studies were identified, five of which compared epidural vs patient controlled analgesia/intra-venous morphine. There were no significant differences between the groups in terms of outcomes, except pain control which was superior in the epidural group. Spinal anaesthesia using intrathecal morphine in addition to local anaesthetic, and the use of nonsteroidal anti-inflammatory agents have also been shown to reduce postoperative pain. CONCLUSION: There is a paucity of data assessing the benefits of postoperative analgesic regimes following laparoscopic colorectal surgery and none of the protocols were shown to be clearly superior. Further studies, including the assessment of spinal analgesia are required to determine the most appropriate analgesic regime following laparoscopic colorectal surgery.

23-hour-stay laparoscopic colectomy.

PURPOSE: The combination of laparoscopic colorectal surgery together with an enhanced recovery program has resulted in short hospital stays. The purpose of this study was to assess the acceptability and safety of a 23-hour-stay protocol developed for patients undergoing laparoscopic colectomy. METHODS: Patients undergoing elective laparoscopic colorectal resection who met the inclusion criteria were invited to participate in the study. A specific preoperative, anesthetic, and postoperative protocol was used. Patients were discharged 23 hours after the start of surgery. Follow-up was by telephone contact on the evening of the day of discharge with outpatient follow-up at Day 3. RESULTS: Ten patients were included in the study. All patients were discharged within 23 hours from the commencement of surgery. There were no complications and no readmissions to the hospital. All patients were satisfied with the service; all ten would request to follow the same pathway again if required, and all would recommend it to other patients. CONCLUSION: A 23-hour-stay laparoscopic colectomy is possible with modification of the enhanced recovery program. Patients find it acceptable and it seems to be safe.

Cholangiocarcinoma, renal cell carcinoma and parathyroid adenoma found synchronously in a patient on long-term methotrexate.

Cases of patients developing lymphoma and cutaneous neoplasms after long-term methotrexate therapy are well documented in the literature; however, there are no reported cases of other neoplasms resulting from methotrexate therapy. A 52-year-old woman who had been on methotrexate for 9 years for psoriatic arthritis was found to have abnormal liver function tests on screening. Investigation with ultrasound, CT scanning and MRCP showed a hilar cholangiocarcinoma and a synchronous right renal tumour. A left hemi-hepatectomy extended to segments 5 and 8 with the formation of a hepaticojejunostomy was performed for a poorly differentiated infiltrative hilar cholangiocarcinoma. This was combined with a right radical nephrectomy for a T1 renal cell adenocarcinoma. Postoperative vomiting was subsequently found to be due to hypercalcaemia and primary hyperparathyroidism. A parathyroid adenoma was later excised. It seems likely that treatment with methotrexate was causal in the development of these three non-cutaneous neoplasms-two malignant and one benign.

MRSA in patients presenting with femoral fractures.

AIM: To assess MRSA carrier status in patients from different residences presenting with femoral fractures and to assess the incidence of MRSA deep wound infections post-operatively with regard to MRSA status on presentation. METHOD: One hundred and five patients were screened for MRSA on arrival over a 20-week period. They were then followed up post-operatively to determine the number of patients developing MRSA deep wound infection. RESULTS: One out of three patients came from an institution (nursing, residential home or hospital). Nearly one in four of these patients were MRSA carriers, compared with a carrier rate of less than 1 in 20 in patients admitted from home. Of the 11 cases presenting as MRSA carriers, two developed a MRSA deep wound infection, compared with 2 out of the 94 patients not colonised with MRSA (X2 p < 0.01).

Long-term survival with stage IV poorly differentiated pancreatic adenocarcinoma.

BACKGROUND: Metastatic poorly differentiated adenocarcinoma of the pancreas has a poor outcome despite the use of various chemotherapy regimes. CASE OUTLINE: A 57-year-old woman presented with a 3-month history of generalised abdominal pain associated with weight loss. Computed tomography (CT) showed a large tumour in the head and body of pancreas, and needle biopsy confirmed a poorly differentiated adenocarcinoma. Laparoscopy revealed liver metastases in both lobes, again histologically shown to be poorly differentiated adenocarcinoma. Six cycles of cisplatin, epirubicin and infusional 5-fluorouracil were given. Five years later the patient remains completely well. Repeat CT scans show a complete radiological response. DISCUSSION: Previous studies using numerous chemotherapy regimes have not significantly altered the outcome of pancreatic cancer. To the best of our knowledge this is the longest surviving case of a patient with advanced metastatic adenocarcinoma (stage IV) of the pancreas treated with chemotherapy.

A positive view of psychiatrists and psychiatry.

A review of the literature on the personalities, mental health, and professional status of psychiatrists was the basis of a questionnaire designed to assess perceptions of these characteristics by psychiatrists themselves and by their medical colleagues. The 374 physician respondents were divided into two groups, psychiatrists and nonpsychiatrists, and beliefs and perceptions were compared between the two groups and with findings from the research literature. Results revealed some differences in opinion between psychiatrists and nonpsychiatrists, most notably concerning the mental health of psychiatrists. This was also the area in which the literature was least conclusive. Findings indicated, however, that physicians across specialties have a positive overall opinion of psychiatrists and their professional worth, and that psychiatrists see themselves as healthy, effective, and useful practitioners.

Are schizophrenics with abnormal dexamethasone suppression test results a distinct subgroup?

Nonsuppression on the dexamethasone suppression test (DST) in schizophrenics has been reported by three independent groups. To elucidate the significance of this finding a schizophrenic cohort was tested on a wide range of parameters: computed tomography (CT), electroencephalography (EEG), the Halstead-Reitan Neuropsychological Battery (HRB), platelet monoamine oxidase activity (MAO), serum dopamine-beta-hydroxylase levels (DBH), premorbid personality adjustment, response to medication and family history of mental illness. Our results indicate that DST nonsuppressing and DST suppressing schizophrenics are no different on any of these measures, lending support to the notion that DST nonsuppression in schizophrenics is a random and changing event.

The ventricular system in chronic schizophrenic patients. A controlled computed tomography study.

Twenty-three chronic schizophrenic patients and 23 controls, all males between 20 and 40 years of age, were evaluated by CT scan. The lateral, third and fourth ventricles, the Sylvian fissures, and the largest sulcus from each of the frontal, parietal, and occipital lobes, were measured in order to determine whether the previously reported ventriculomegaly in schizophrenics was perhaps due to a disturbance of CSF flow or to atrophy, two common causes of ventricular enlargement. We found that in the schizophrenic group the third and fourth ventricles and both Sylvian fissures were significantly enlarged, but not the lateral ventricles or cerebral sulci. Our data suggest that these ventricular changes are not due to a disturbance of CSF flow or to cerebral atrophy. Other possible explanations are discussed.

Cerebellar morphology in chronic schizophrenic patients: a controlled computed tomography study.

Simple, objective, linear, and density measures were used to evaluate by computed tomography (CT) the cerebellum-fourth ventricular region of 23 chronic schizophrenic patients and 23 normal controls. Our data suggest that a subgroup of chronic schizophrenic patients have cerebellar atrophy associated with a strong but nonsignificant trend toward increased cerebellar density. The implications of these findings are discussed in view of previous CT and neuropathological studies.