Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study.

AIM: Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. METHODS: Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. RESULTS: A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ=0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. CONCLUSIONS: The results demonstrate that MR proctography under-reports pelvic floor abnormalities especially where there has been poor rectal evacuation.

An improved technique for Soave trans-anal pull-through.

AIM: To describe a new technique for the Soave trans-anal pull-through. METHOD: After the mucosectomy during a Soave's procedure, a laparoscopic wound retractor was used to line the distal rectal segment to facilitate delivery of the proximal bowel through a narrow scarred pelvis. RESULTS: The technique greatly assisted delivery of the proximal bowel and helped prevent mesenteric injury. CONCLUSION: Soave trans-anal pull-through is a difficult operation that is largely confined to specialist centres. We describe an improvement to the technique that greatly facilitates the procedure.

Single-incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis.

AIM: Single-incision (or port) laparoscopic surgery (SILS) has recently emerged as a method to improve morbidity and cosmetic benefit of conventional laparoscopic surgery. The literature contains two reports of SILS right hemicolectomy, and we report our experience of this technique. METHOD: Seven consecutive, unselected patients underwent SILS retrocaecal appendicectomy, right hemicolectomy, extended right hemicolectomy, colectomy with ileorectal anastomosis, proctocolectomy, anterior resection and restorative proctocolectomy/ileoanal pouch using a single Triport (Olympus Keymed, Southend, UK), conventional instrumentation and nerve block analgesia. Three had undergone previous surgery, two had cancer and two were immunosuppressed. RESULTS: Umbilical, right- and left-iliac fossa SILS was feasible using conventional instruments. Operative time ranged between 23 and 195 min (median 48 min). Four patients tolerated normal diet within 6 h (12-16 h for the remainder). Only one patient required postoperative enteral morphine (10 mg × 4). Discharge occurred between 8 and 90 h (median 16 h) of surgery. A secondary haemorrhage from the ileorectal anastomosis was managed conservatively. CONCLUSION: SILS colorectal resection is feasible and safe when performed by an experienced laparoscopic surgeon and theatre team. It may have advantages over conventional laparoscopic surgery in terms of reduced pain, lower cost, faster recovery and cosmesis.

National UK audit of procedure for prolapsing haemorrhoids on behalf of the Association of Coloproctology of Great Britain and Ireland.

OBJECTIVE: To assess the safety and short term outcomes of the procedure for prolapsing haemorrhoids (PPH), a relatively new procedure for the treatment of symptomatic haemorrhoids. METHOD: In 2005, the Association of Coloproctology of Great Britain and Ireland set up an online electronic database to audit the indications and outcomes for patients undergoing a PPH procedure. RESULTS: During the audit period, 695 patients were entered onto the database by 61 surgeons (range 1-50 patients per surgeon). The main indications for surgery were bleeding (90.5%) and prolapse (83.9%). Three hundred and ninety-seven (57.1%) patients had grade III or IV haemorrhoids. PPH was performed under general anaesthetic in 602 (86.6%) cases and a consultant surgeon performed the procedure in 572 (82.3%) cases. The median length of stay was 1 day (range 0-6 days). Two hundred and eighty-nine (41.6%) procedures were performed as a day case. Immediate complications were recorded in 75 (10.8%) patients, the commonest being bleeding (21) and urinary retention (24). At 6-week follow-up, 626 (90.1%) patients were pain free. Five patients required hospital re-admission for secondary haemorrhage (3), peri-anal abscess (1) and pain (1). The commonest problems were minor bleeding (48), urgency (22), pain (14), continued prolapse (12) and pruritus (11). Four patients required an open haemorrhoidectomy for persistent symptomatic haemorrhoids. CONCLUSION: Procedure for PPH is a safe and effective procedure for symptomatic haemorrhoids with good short-term outcomes. Long-term follow-up is required perhaps through a compulsory national register.

Acute Abdominal Pain for the General Physician - who, when and how to refer to the on-call surgeon.

Patients with abdominal pain are most frequently referred to the on-call surgical team, but there are occasions when physicians may be required to assess, investigate or treat such patients. This article aims to equip non-surgeons with the skills to undertake an appropriate initial assessment and consider the most appropriate selection, timing and mode of referral to the surgical team.

Serum trypsinogen activation peptide in the assessment of the diagnosis and severity of acute pancreatic damage: a pilot study using a new determination technique.

OBJECTIVES: To evaluate the clinical value of a new direct and competitive immunoassay for trypsinogen activation peptide (TAP) determination in acute pancreatitis (AP). METHODS: The subjects were 34 patients with AP (22 mild, 12 severe), 12 patients with nonpancreatic acute abdominal pain (AA), 11 healthy subjects (HS), and 16 consecutive patients who underwent therapeutic ERCP (ERCP). Serum TAP, amylase, and lipase levels were determined in AP, AA, and HS at their initial observation; the AP patients were also studied for 6 consecutive days after admission. In the ERCP patients, serum TAP, amylase, and lipase levels, as well as urine TAP and amylase levels, were determined before and 6 hours after endoscopy. RESULTS: Serum TAP levels on admission were 0.35 +/- 1.60 OD (mean +/- SD) in AP patients and 0.005 +/- 0.001 OD in AA patients, while HS patients had no detectable serum TAP levels. ERCP patients had no detectable serum TAP levels before and 6 hours after the ERCP, whereas urine TAP concentrations were 1.72 +/- 3.43 OD and 0.75 +/- 1.49 OD before and 6 hours after the execution of the endoscopy, respectively (P = 0.249). The sensitivities and specificities of serum TAP, amylase, and lipase levels in discriminating between AP and AA were 23.5% and 91.7%, 94.1% and 100%, and 97.1% and 100%, respectively, while those used in the assessment of the severity of AP were 29.9% and 73.5%, 38.8% and 81.2%, and 28.4% and 83.6%, respectively. CONCLUSION: TAP is of limited value in assessing the diagnosis and the severity of acute pancreatic damage.

Pharmacological and toxicological aspects of 4-demethoxy-3'-deamino-3'-aziridinyl-4'-methylsulphonyl-daunorubicin (PNU-159548): a novel antineoplastic agent.

4-demethoxy-3'-deamino-3'-aziridinyl-4'-methylsulphonyl-daunorubicin (PNU-159548) belongs to a novel class of antitumor compounds (termed alkycyclines) and is currently undergoing Phase II clinical trial. In the present study, we investigated the in vitro and in vivo antitumor activity, the pharmacokinetics, and the toxicological profile of this compound. PNU-159548 showed good cytotoxic activity in murine and human cancer cells growing in vitro, with an average concentration for 50% growth inhibition of 15.8 ng/ml. The drug showed strong antitumor efficacy in vivo after i.v. and p.o. administration against rapidly proliferating murine leukemias and slowly growing transplantable human xenografts. At non-toxic doses, PNU-159548 produced complete regression and cures in ovarian, breast, and human small cell lung carcinomas. Fourteen of 16 models studied, including colon, pancreatic, gastric, and renal carcinomas, astrocytoma and melanoma, were found to be sensitive to PNU-159548. In addition, PNU-159548 was effective against intracranially implanted tumors. Toxicological studies revealed myelosuppression as the main toxicity in both mice and dogs. The maximum tolerated doses, after a single administration, were 2.5 mg/kg of body weight in mice, 1.6 mg/kg in rats, and 0.3 mg/kg in dogs. In the cyclic studies, the maximum tolerated doses were 0.18 mg/kg/day (cumulative dose/cycle: 0.54 mg/kg) in rats and 0.05 mg/kg/day (cumulative dose/cycle: 0.15 mg/kg) in dogs. PNU-159548 showed minimal cardiotoxicity, when compared with doxorubicin in the chronic rat model at a dose level inducing similar myelotoxicity. Animal pharmacokinetics, carried out in mice, rats, and dogs, was characterized by high volumes of distribution, plasma clearance of the same order of the hepatic blood flow, and short terminal half-life. These findings support the conclusion that PNU-159548 is an excellent candidate for clinical trials in the treatment of cancer.

A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis.

BACKGROUND: A diagnostic scoring system such as the modified Alvarado score, combined with selective laparoscopy in adult females, can be used in the assessment of acute abdominal pain suggestive of appendicitis. METHOD: A total of 84 consecutive patients presenting to our surgical team with suspected appendicitis were assessed prospectively using the modified Alvarado score. The definitive management of this study group was instigated according to a set algorithm based on the score. The algorithm included the use of diagnostic laparoscopy in adult female patients with scores suggestive of appendicitis. A negative appendicectomy rate was obtained from those undergoing appendicectomy using this approach and compared to that obtained from the 97 patients that had undergone appendicectomy under the care of the other surgical teams in our unit during the study period. RESULTS: The rate of negative appendicectomy in the study group was 0% compared to 18% in the control group (P < 0.05); 10% of adult female women had negative diagnostic laparoscopies for appendicitis thus saving this group an unnecessary appendicectomy. This was achieved without an increase in total in-patient stay. CONCLUSION: An algorithm combining the modified Alvarado score with selective laparoscopy is recommended for widespread use in the management of suspected acute appendicitis.

A 14-year experience with 6 cm as a criterion for surgical treatment of abdominal aortic aneurysm.

BACKGROUND: It remains unclear when to recommend operation for an asymptomatic abdominal aortic aneurysm (AAA). This study examined a prospective series of patients for whom standard criteria were applied. METHODS: Some 584 consecutive patients with an AAA of diameter 3 cm or greater detected by ultrasonographic screening have been observed for up to 14 years. Repeat ultrasonographic examinations have been performed at intervals. Surgery was not considered unless the aneurysm measured 6 cm in diameter, expanded at a rate equivalent to at least 1 cm per year, caused the patient symptoms, or an iliac aneurysm was present that required treatment. RESULTS: Operation was performed on 127 patients; the majority (80; 63 per cent) had an aneurysm that reached 6 cm in diameter. Use of the above criteria prevented rupture in all but 24 (4 per cent) of the 584 patients over the 14-year interval. Of these 24 patients, 11 were unfit for planned surgery and eight declined operation or follow-up. Rupture in the five remaining patients (1 per cent) who were available for treatment compared favourably with the reported 30-day mortality rate for elective surgical treatment of 1.4-12 per cent. CONCLUSION: Repeated observation is preferable to surgical intervention until an aortic aneurysm measures 6 cm in diameter, expands by 1 cm per annum or causes symptoms. Presented as a poster to the 52nd Annual Meeting of the Society for Vascular Surgery, San Diego, California, USA, June 1998

Traumatic avulsion of the ulnar collateral ligament of the IP joint of the thumb.

We present a previously undescribed injury of avulsion of the ulnar collateral ligament of the thumb IP joint. Stress radiographs may be used to confirm the diagnosis in cases of clinical suspicion.

Behaviour problems and pre-school intellectual attainment: the associations of hyperactivity and conduct problems.

The relationship between behaviour problems and intelligence was examined in a sample of 106 three-year-old boys and girls selected for the presence of either conduct problems or hyperactivity. Parents' reports of hyperactivity, but not conduct problems, were negatively related to IQ scores for both boys and girls. There was a significant sex difference in the association between conduct problems and IQ. For girls IQ was positively correlated with conduct problems. The implications of the results for existing models of the relationship between behavioural deviance and cognitive functioning in childhood is discussed.