Massive Small Bowel Enterolith in Post Cystoprostatectomy Ileal Cul-de-sac : A Unique Presentation of a Rare Clinical Condition.

Enterolithiasis or formation of gastrointestinal concretions is an unusual medical entity that typically occurs in patients suffering from persistent intestinal stasis. We present a rare case of non-obstructive enterolith wedged in the blind end of bowel reconstruction following cystoprostatectomy and ileal conduit formation due to muscle-invasive bladder cancer. Although we watched it grow over the years, radiological characterisation was made possible when it grew to a significant size. We, herein, will discuss the aetiology and complexities associated with the diagnosis and management of such orphan cases given their non-specific clinical presentations in an already hostile abdomen due to multiple laparotomies.

AIE-active Ir(III) complexes as type-I dominant photosensitizers for efficient photodynamic therapy.

The ability of a photosensitizer (PS) to generate reactive oxygen species (ROS) including type I oxygen free radicals and type II 1O2 is pivotal for photodynamic therapy. Luminescent Ir(III) complexes are effective PSs with high 1O2 generation ability owing to their high intersystem crossing ability and effective energy transfer to 3O2. However, so far, reports on type I ROS based on ˙OH generation induced by Ir(III) PS are still rare. In this work, four novel aggregation-induced emission (AIE)-active Ir(III) PSs, namely MFIriqa, MFIrqa, SFIriqa, and SFIrqa have been designed and synthesized, which show highly efficient emission in the aggregated state. Cell imaging experiment results indicate that all four Ir(III) PSs can effectively improve the signal-to-noise ratio of imaging by reducing the interference from the background due to their fascinating AIE properties. Importantly, in vitro, Ir(III) PSs MFIrqa, SFIriqa, and SFIrqa nanoparticles show obvious photodynamic activity toward cancer cells upon irradiation accompanied by type I ˙OH generation, which may be attributed to the unique excited-state characteristics of Ir(III) complexes. This work will provide guidance for the construction of a type I photosensitizer based on the AIE-active Ir(III) complex, which offers great advantages for potential clinical applications under hypoxic conditions.

Metal ions doped into merocyanine form of coumarin derivatives: nonlinear optical molecular switches.

In the present study, DFT calculations are carried out on domestically designed 7-methyl-2-phenyl-5'H-spiro[chromene-4,2'-chromeno[3,4-e][1,3]oxazin]-5'-one spiropyran and merocyanine derivatives to recognize alkali and alkaline earth metal ions. Detection of these metal ions can be attained by exploiting the variation of the second-order nonlinear optical properties. Merocyanine forms of these derivatives exhibit the ability to complex with different metal ions (Li+, Na+, K+, and Ca2+), which is associated with large contrasts in the hyper-Rayleigh scattering (HRS) response as a function of metal size and charge. Interestingly, in this study, Mero-Li+ shows significant nonlinear optical response with dynamic HRS first hyperpolarizability amounting to 7607 a.u., which is about nine times higher than its corresponding spiro form (846 a.u.) at the CAM-B3LYP/6-311G* level of theory. The present investigation clarifies the effect of metal nature on the enhancement of the first hyperpolarizability between the closed and open forms of the studied coumarin derivatives. Graphical abstract The coumarin-based compound 3 demonstrate the higher second-order NLO responses as a function of metal cation size and charges. Complexation of smaller alkali metal ions leads to the formation of stronger metal-ligand bonds, larger geometrical relaxations and significant enhancement of the HRS first hyperpolarizabilities. This present investigation elucidates the effect of metal nature on the enhancement of the first hyperpolarizability between the closed and open forms of studied coumarin derivatives.

Quality improvement measures: effects on rectal cancer tissue biopsy process.

PURPOSE: Delay in histologically confirming rectal cancer may lead to late treatment as histological confirmation is required prior to chemo-radiotherapy or surgical intervention. Multidisciplinary colorectal meetings indicate that there are patients who require multiple tissue biopsy episodes prior to histologically confirming rectal cancer. The purpose of this paper is to examine a quality improvement (QI) measure's impact on tissue biopsy process diagnostic yield. DESIGN/METHODOLOGY/APPROACH: The authors performed the study in two phases (pre- and post-QI), between February 2012 and April 2014 in a district general hospital. The QI measures were derived from process mapping a rectal cancer diagnostic pathway. The primary outcome was to assess the tissue biopsy process diagnostic yield. The secondary outcome included total breaches for a 62-day target in the pre- and post-QI study phases. FINDINGS: There was no significant difference in demographics or referral mode in both study phases. There were 81 patients in the pre-QI phase compared to 38 in the post-QI phase, 68 per cent and 74 per cent were referred via the two-week wait urgent pathway, respectively. Diagnostic tissue biopsy process yield improved from 58.1 to 77.6 per cent after implementing the QI measure ( p=0.02). The 62-day target breach was reduced from 14.8 to 3.5 per cent ( p=0.42). PRACTICAL IMPLICATIONS: Simple QI measures can achieve significant improvements in rectal cancer diagnostic tissue biopsy process yields. A multidisciplinary approach, involving process mapping and cause and effect modelling, proved useful tools. ORIGINALITY/VALUE: A process mapping exercise and QI measures resulted in significant improvements in diagnostic yield, reducing the episodes per patient before histological diagnosis was confirmed.

Right and Transverse Colonic Multi-Visceral Resections for Locally Advanced Cancers-a Single-Center Experience.

Locally advanced colorectal tumors constitute to about 5-22% of all colorectal cancers at the time of presentation. Multi-visceral resection is usually required for such cases in order to achieve curative resection (R0). We aim to present our experience of right and transverse colonic en bloc resections and their outcomes. Retrospective review of a prospective database between February 2008 and December 2014. Case notes, operative findings, histopathology results, and follow-up records were analyzed. A total of 23 patients underwent en bloc multi-visceral resections for locally advanced right-sided or transverse colonic cancers. There were 11 males and 12 females. The mean age was 75 years. Fifteen patients were operated electively and eight were done as emergency. Median follow-up was 36 months. Eleven out of 23 (47%) had more than one organ resected. 78.3% had R0 resections, 17.4% were R1, and 4.3% were indeterminate. The average lymph node yield was 22 [range 5-45]. Senior trainees under supervision did 65% of procedures. Twelve-month disease-free survival was 90% and the 5-year survival was 65%. Right-sided and transverse colonic tumors have a propensity to become locally advanced making curative resections challenging. This is especially relevant when these patients present as an emergency or if the surgeon is less experienced and may opt for a palliative procedure, thus leading to suboptimal outcomes. Multi-visceral resections for locally advanced tumors can be feasible in the district general hospital setting with acceptable outcomes. Multi-disciplinary meeting (MDM) process, adequate training, and experience are vital.

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience.

OBJECTIVES: To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF. METHODS: Medline and Embase database were searched for the words 'pilonidal, sinus, Limberg, flap'. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected. RESULTS: Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0-7.4% in case series. Recurrence rate in comparative studies was 0-8.3%, compared to 4-37.7% for primary closure and 0-11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% - [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months. CONCLUSIONS: Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.

Subacute bowel obstruction secondary to an obturator hernia: case report and a review of the literature.

Obturator hernias are rare and are often diagnosed late. This case report discusses an 82-year-old female who had symptoms of subacute bowel obstruction. Following a computed tomography abdomen pelvis, she underwent a laparotomy for an incarcerated right obturator hernia. The hernia was repaired using a single suture and she made a good recovery. A review of the literature around obturator hernias is discussed.

Amyand's hernia managed with open repair and laparoscopic appendicectomy.

We present a rare case of Amyand's hernia that was surgically managed using an open repair of hernia combined with laparoscopic appendicectomy. A 68-year-old man presented with an irreducible recurrent right-sided inguinal hernia and abdominal pain. This gentleman had undergone three previous inguinal hernia repairs on the right, and one on the left using the open mesh technique. Ultrasound suggested the possibility of the appendix within the hernial sac and clinical correlation was advised. An open groin approach was taken to repair the incarcerated hernia. This revealed an indirect inguinal hernia containing the appendix with signs of inflammation. The base of the appendix was not visible due to there being a long appendix with fixed cecum in the abdomen. To safely resect the appendix, a laparoscopy was performed and the appendix was successfully removed. The inguinal hernia was repaired using a sutured technique without mesh. There were no post-operative complications.

Prevascular femoral hernia and its relation with inferior epigastric vessels: a rare presentation of the femoral hernia sac.

A 61-year-old man presented to the emergency department, with a 2-week history of a painful lump on his right groin. A diagnosis of an irreducible right femoral hernia was made. As such, an urgent operation was carried out on the same day, and the patient was found to have a rare prevascular femoral hernia in which the sac was lying over the femoral vessels and split by the inferior epigastric vessels into 2 components resembling 2 trouser limbs. The hernia sac presented in a different and challenging way that necessitated meticulous dissection and full orientation of the anatomy of the femoral triangle. Complete dissection and control of the inferior epigastric vessels, and complete reduction of the sac followed by repair with a prosthetic mesh plug were performed successfully. The patient was discharged home the next day.

Implementing a Pro-forma for Multidisciplinary Management of an Enterocutaneous Fistula: A Case Study.

Optimal management of patients with an entercocutaneous fistula (ECF) requires utilization of the sepsis, nutrition, anatomy, and surgical procedure (SNAP) protocol. The protocol includes early detection and treatment of sepsis, optimizing patient nutrition through oral and parenteral routes, identifying the fistula anatomy, optimal fistula management, and proceeding to corrective surgery when appropriate. The protocol requires multidisciplinary team (MDT) coordination among surgeons, nurses, dietitians, stoma nurses, and physiotherapists. This case study describes a 70-year-old man who developed an ECF subsequent to a laparotomy for a small bowel obstruction. Following a period of ileus, 16 days post laparotomy the patient developed a high-output (2,000 mL per day) fistula. The patient also became pyrexial with raised inflammatory markers, requiring antibiotic treatment. Following development of his ECF, he was managed using the SNAP protocol for the duration of his admission; however, in implementing this protocol with this patient, clinicians noted fluid charts were inadequate to allow effective management of the variables. Thus, a new pro-forma was created that encompassed fluid balance, nutritional status, and pertinent blood test results, as well as perifistular skin condition, medication, and documentation of management plans from the MDT team. The pro-forma was recorded daily in the patient notes. Following implementation of the pro-forma and the SNAP protocol, the patient recovered well clinically over a period of 4 weeks with a decrease in his fistula output to 300-500 mL per day, and he was discharged with plans for further corrective surgery to resect the fistula and for bowel re-anastomoses. Although fluid charts are readily available, they do not include all pertinent variables for optimal management of patients with an ECF. Further research is needed to validate the pro-forma and evaluate its effect on patient outcomes.

Digital assessment of lower rectum fixity in rectal prolapse (DALR): a simple clinical anatomical test to determine the most suitable approach (abdominal versus perineal) for repair.

Selection of an appropriate approach to treat full thickness rectal prolapse remains problematic and controversial. We propose that rectal prolapse may be classified as 'low type' (true rectal prolapse) or 'high type' (intussusception of the sigmoid with a fixed lower rectum). This assessment can be made via a simple clinical test of digital rectal assessment of lower rectal fixity ('the hook test') based on anatomic changes in rectal prolapse to guide the selection process. In cases with the low-type prolapse, a perineal approach is appropriate (either Delorme's procedure, or rectosigmoidectomy with or without pelvic floor repair). For the high type, an abdominal rectopexy with or without high anterior resection is needed. Retrospective analysis of our cases treated over the last 6 years showed a recurrence rate of 6% in perineal procedures and 0% in abdominal rectopexy combined with resection to date. We believe that employing our simple test and classification can contribute to better patient selection for either approach, minimize anaesthetic and surgical risks and also result in lower recurrence rates.