Laparoscopic excision of retrorectal schwannoma.

The short-term benefits of laparoscopic resection for standard tumors of the colon and rectum are well accepted. Retrorectal tumors are relatively uncommon, and there have been few reports of laparoscopic techniques being applied to such tumors. This video article presents a laparoscopic approach to a retrorectal schwannoma, highlights the technical challenges of such a procedure, and offers some operative tips to aid management of such tumors (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A29).

Surgeon perspectives on options for ventral abdominal wall hernia repair: results of a postal questionnaire.

BACKGROUND: Ventral abdominal wall hernias are a common cause of morbidity and mortality. Opinion varies as to appropriate management. A recent consensus meeting on incisional hernia identified the need to standardise repair. On this background, a survey of current practice was performed. METHOD: A questionnaire was sent to 101 practicing general surgeons within the West of Scotland. Incisional, epigastric and para-umbilical defects were subdivided into defect size <2, 2-5 and >5 cm. The surgeons were asked to indicate the most appropriate repair (suture, mayo or mesh) for each. The influence of reducibility on the decision to repair was also assessed. RESULTS: Sixty-one of 101 questionnaires were returned valid giving a response rate of 60%. Suture repair was significantly more likely to be used in all defects <2 cm (P<0.001). Mesh repair was significantly more likely to be recommended in all defects >5 cm (P<0.001). Of defects >5-cm, mesh was recommended for 90% of incisional hernia compared with 81% of epigastric and 76% of para-umbilical hernia (P<0.001). There was no significant difference in choice of repair for defect size 2-5 cm with opinion divided between suture and mesh. Irreducibility increased the likelihood of recommendation for repair. CONCLUSION: This survey shows a lack of consensus on the appropriate repair of ventral abdominal wall hernia among practicing consultant general surgeons. This reflects the contrasting views within the current literature.

Missed diagnoses in patients with upper gastrointestinal cancers.

BACKGROUND AND STUDY AIMS: A few studies have been published on cancers missed at previous endoscopy, but detailed analyses of the causes for failure were lacking. The aims of our study were to determine the incidence of and causes for failure to detect oesophageal and gastric cancers after referral of patients to a surgical endoscopy unit. PATIENTS AND METHODS: Out of a consecutive series of 305 patients diagnosed with oesophageal and gastric cancers, we retrospectively identified patients who had undergone an endoscopy within 3 years before the diagnosis. The timing of previous endoscopies, indications for endoscopy, endoscopic findings and the number of biopsy specimens taken were recorded. Missed diagnoses were categorized as either definitely or possibly missed and the reasons for failure were documented. RESULTS: Of the 305 patients, 30 (9.8 %) had undergone a minimum of one endoscopy within the previous 3 years, 20 (67 %) of these within the previous 1 year. Sinister symptoms were present at the time of previous endoscopies in 75 % of patients with oesophageal cancer (n = 16) and in 57.2 % of patients with gastric cancer (n = 14). In 56 % of the patients with oesophageal cancers the initial diagnosis was oesophagitis or benign stricture; in 71.4 % of the patients with gastric cancers the initial diagnosis was gastritis, ulcer or "suspicious lesion". Among those patients with a definitely missed diagnosis (7.2 %), endoscopist errors accounted for the majority of failures (73 %) and the remainder were due to pathologist errors (27 %). CONCLUSIONS: Missed cancers were a frequent finding in patients with oesophageal and gastric cancer who had undergone previous endoscopy, and errors by the endoscopists accounted for the majority of missed lesions. This study emphasizes the importance of identifying signs of early cancers and of having a low threshold for performing multiple biopsies of any suspicious-looking lesion.

Carcinogenic potential of commonly used hernia repair prostheses in an experimental model.

BACKGROUND: The purpose of this study was to assess the carcinogenic potential of commonly used hernia repair prostheses in an animal model. METHODS: Three types of prosthetic material (monofilament polypropylene, multifilament polypropylene and expanded polytetrafluoroethylene) were implanted in CBA/H mice. Flat (1 cm(2)) and rolled pieces of the same material were placed subcutaneously in either flank, and a further flat piece was placed in the preperitoneal space. Owing to a high incidence of mesh extrusion in the polypropylene groups, the study protocol was modified to allow only preperitoneal placement of the material. A fourth, control, group had the pockets for the prostheses created but no material implanted. After modification of the protocol there were approximately 60 mice in each group. The mice were followed for 2 years, then killed and assessed histologically for tumour development. RESULTS: No sarcoma developed at the site of mesh implantation in any of the groups. CONCLUSION: This study indicates that the risk of sarcoma formation at the site of hernia repair prostheses is very low.

Time and money: effects of no-shows at a family practice residency clinic.

BACKGROUND: When patients fail to appear for scheduled appointments, the flow of patient care is interrupted, and clinic productivity declines. This study investigated the impact of failed appointments on a clinic by measuring time and money lost after taking into account same-day treatment patients (walk-ins). METHODS: Schedule information was retrieved for 4,055 visits over 20 business days. Data were collected on appointment status (show, no-show, cancel, walk-in), time allocated for the appointment, charges for visit, date and time of the visit, and other appointment information. RESULTS: No-shows and cancellations represented 31.1% of scheduled appointments and 32.2% of scheduled time. Rates of failed appointments varied by type of provider, patient demographics, and patient status (new versus established). Walk-in patients replaced 61.0% of failed appointments but only 42.4% of the time blocked for those appointments. Walk-in visits generated 89.5% of the charges associated with scheduled visits. Over the course of a year, total revenue shortfalls could range from 3% to 14% of total clinic income. CONCLUSIONS: Failed appointments pose financial as well as administrative problems for residency practices. Proactive reminder systems are needed to promote patient attendance.

Geologic storage of radioactive waste: field studies in Sweden.

Access to a granitic rock mass in an iron ore mine in Sweden provided a unique opportunity for underground experiments related to the geologic disposal of radioactive waste. These field tests demonstrated the importance of hydrogeology and the difficulties in predicting the thermomechanical behavior of fractured granitic rocks. To characterize a site fully, measurements made from the surface must be supplemented by extensive subsurface measurements and experiments. Much effort is needed at this stage to generate the technology required for the development of waste repositories.