Mental rehearsal: A useful simulation adjunct to surgical training.

BACKGROUND: Simulation is an effective adjunct to surgical training. There is increasing interest in the use of mental rehearsal as a form of cognitive simulation. The mental visualisation of a motor skill is recognised to enhance performance; a concept not novel to surgeons. Despite this, mental rehearsal has yet to be formally incorporated into surgical training. This study aims to assess the use of mental rehearsal amongst general surgical trainees and consultants. METHOD: A six-item questionnaire was designed and electronically circulated to general surgical core trainees, registrars, fellows and consultants. Qualitative and quantitative analysis was independently performed. RESULTS: 153 responses (consultants = 51.6%, trainees = 48.4%) were received over 3 weeks. 91.5% of surgeons mentally rehearse prior to operating. Its use predominates for complex cases only. There is no difference in case complexity and the surgeon's grade in regard to when mental rehearsal is performed (χ2 = 1.027, p = 0.31). Individual mental rehearsal is preferred. Consultants are more likely to mentally rehearse with others, although there was no statistical difference compared to trainees (χ2 = 0.239, p = 0.63). Clarification, confidence and anticipation of potential difficulties were the perceived benefits of mental rehearsal reported in 58.6% of responses. CONCLUSIONS: Mental rehearsal prior to operating appears instinctive for general surgeons irrespective of seniority and case complexity. Whether the efficacy of mental rehearsal on training is sustained and continues as surgeons progress along the training curve are unknown. Alternative methods of surgical training are very much needed. We propose mental rehearsal.

Negative pressure therapy for stoma closure sites-a nonrandomised case control study.

AIM: The PICO (Smith & Nephew, UK) dressing is a single use negative pressure wound therapy (NPWT) system that is designed to be used for up to 7 days for closed wounds. We aimed to assess its use for stoma closure wounds. METHOD: We conducted a retrospective analysis of stoma reversal wounds from April 2018 to June 2019. The wound was partially closed with an absorbable subcutaneous suture in a purse-string fashion. A 15 cm × 15 cm PICO dressing was applied directly over this wound. A control group who had received partial purse string closure with packing over the same time period was identified. Patients were contacted and information collected using a questionnaire. The primary outcome measure was the number of visits for dressing changes in the community. Further information was collected about length of stay, time to resolution of pain and return to work. RESULTS: On average, the patients with PICO dressings attended the community nurses 1.9 times. The patients in the PICO group stated it took 1-2 weeks to return to full work/daily activities. The control group averaged attending the community nurse 11.9 times, and 33% had not returned to work/daily activities in 1-2 weeks. CONCLUSION: Those who had a PICO dressing required fewer visits to the community nurse and the majority were able to return to work or resume usual activities within 1 to 2 weeks. This pilot study suggests that negative pressure dressings may be a useful aid for stoma closure site wounds.

Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision.

OBJECTIVE: Perineal wound complications after abdominoperineal excision (APE) for anorectal cancer represent a considerable source of morbidity for patients. Strategies to improve wound healing include reconstruction with myocutaneous flaps. This is an evidence-based review of reconstruction of pelvic defects after APE, using rectus abdominus (RAM), gracilis and gluteus maximus flaps. METHOD: A Pubmed search was performed using MESH headings. RESULTS: Thirty-six studies reported outcomes of interest. Five controlled studies reported improved outcomes after APE and chemoradiotherapy with RAM reconstruction and two controlled studies reported improved outcomes with gracilis reconstruction. There were seven patients with total flap loss after RAM reconstruction, in a combined 300 patients. There were eight patients with complete cutaneous necrosis after gracilis reconstruction in a combined 83 patients. CONCLUSION: Data from the controlled studies support the use of myocutaneous flaps for single-stage reconstruction after APE in the presence of chemoradiotherapy. Ultimately, the choice of flap depends on the goals of reconstruction, size of the defect and the availability of donor tissue. The implications of an expanding role for radiotherapy in the treatment of low rectal cancer and radical dissection to achieve negative circumferential margins, necessitate close co-operation between colorectal and reconstructive surgeons to achieve APE with reduced wound morbidity.

Jass staging is a predictor of outcome following "curative" resection of Dukes' B colorectal carcinoma.

BACKGROUND AND AIMS: We have sought to determine if the addition of the Jass pathological classification to Dukes' staging would provide improved prognostic information for patients undergoing curative surgery for Dukes' B colorectal carcinoma. PATIENTS AND METHODS: One hundred and eighty three patients who underwent curative surgery for Dukes' B colorectal cancers between December 1988 and January 1998 were identified. An assessment of Jass scoring was made at the time of initial histological staging. All patients entered a comprehensive follow-up system. RESULTS: Jass grouping was found to correlate significantly with cancer specific mortality rates; group III having a worse prognosis than groups I and II (p<0.005). There was no significant difference between either local recurrence or systemic recurrence and the Jass group. CONCLUSION: The Jass classification provides additional prognostic information in patients following curative resection of Dukes' B colorectal carcinoma and may therefore facilitate the selection of patients who will benefit most from adjuvant treatment

Breast screening: PERFORMS identifies key mammographic training needs.

The UK Breast Screening Programme has recently expanded the age range for invitation in the prevalent round to 70 years. In contrast, fewer radiologists now choose to specialise in the area of breast cancer screening. In response to this depletion in film-reading personnel, an increasing number of radiographers have been trained as advanced practitioners in order to film-read alongside the current radiologists. As part of the quality assurance programme for the National Health Service Breast Screening Programme (NHSBSP), each film-reader can participate in a voluntary self-assessment scheme (Personal Performance in Mammographic Screening, PERFORMS) which consists of a number of recent challenging breast screening cases that are amassed nationally and distributed bi-annually. The scheme produces anonymous data on any areas of difficulties that individual participants have; these data can then be aggregated over groups of participants or over specific types of screening cases. In this paper, the areas of difficulty experienced by groups of advanced practitioners and radiologists on the PERFORMS cases were investigated to determine whether there were occupational group differences in reading skills in terms of case classification and feature type. Identifying if such problematic areas exist would be the first step to provide training sets specially tailored to the needs of particular occupational groups. As a bench mark for which cases could be problematic, the types of cases that a panel of experienced radiologists deemed as difficult was first examined in order to compare the performance of both film-reading groups against this panel standard. Secondly, any differences in performance error and case characteristics (classification, difficulty level and feature type) between radiologists and advanced practitioners were examined. The decisions of 15 experienced "panel" radiologists and approximately 400 film readers (including radiologists and advanced practitioners) were compared on 180 cases, over a number of years. This study employed a matched design which controlled for any differences between radiologists and advanced practitioners in terms of real-life factors, such as volume of cases read per week and years of radiological experience. The results elucidate the type of cases most appropriate for advanced mammographic training. No significant differences were found between the advanced practitioners and radiologists on these self-assessment screening cases, indicating that dedicated occupational group training is not required.

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage.

OBJECTIVE: Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment. PATIENTS AND METHODS: GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour. RESULTS: There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005). CONCLUSION: Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.

Inflammatory bowel disease and pregnancy.

The peak age ranges for pregnancy and inflammatory bowel disease (IBD) coincide, and many women develop IBD during their reproductive years. This contribution reviews the major studies on the subject, and is sub-divided into two broad considerations: the effects of the disease on fertility, pregnancy and other factors related to the puerperium, and, conversely, the effects of pregnancy and childbirth on the disease: its natural history and recent surgical treatment options, namely pouch anatomy and function. A systematic review of the literature from 1950 to the present was undertaken using Medline and the keywords inflammatory bowel disease and pregnancy.

Diagnostic lessons learnt from a series of enterovesical fistulae.

OBJECTIVE: An enterovesical fistula (EVF) is an uncommon condition requiring careful and sometimes extensive preoperative investigation. Our experience over a 10-year period has been reviewed with emphasis on the diagnostic investigations performed. PATIENTS AND METHOD: Forty-two patients (30 male) have been studied. Presenting symptoms, diagnostic investigations, and subsequent treatment have been reviewed. RESULTS: The site of the fistulae were; 37 colonic, 2 rectal, and 3 ileal. The commonest presenting symptoms were; pneumaturia 75%, faecaluria 63% and urinary tract infections 57%. The positivity rate of the investigations performed were; cystoscopy 89%, urine cytology 86%, barium enema 65%, computerized tomography (CT) scanning 55%, IVP 35%, and cystography 27.5%. The causes of the fistula were; diverticular disease 71%, carcinoma 20%, Crohn's disease 7%, and radiotherapy 2%. CONCLUSIONS: We recommend cystoscopy and urine cytology for faecal material as the first-line investigations in all patients with a suspected enterovesical fistulae. CT scanning and barium enema should not be first line investigations but may be performed subsequently to help determine the aetiology and planning of surgery.

Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic.

BACKGROUND: Pruritus ani is a common and socially embarrassing condition which is often poorly managed. It is often classified as idiopathic where the symptoms are usually transitory or secondary when a more persistent itch is experienced. The aim of this study was to establish the cause of pruritus ani in a group of patients referred to a combined colorectal and dermatological clinic, and to determine the most appropriate treatment. METHODS: Forty consecutive patients with pruritus ani were referred over a 6-month period from either the general practitioner or another hospital consultant to a combined colorectal and dermatological clinic. They were assessed by history, completion of a general health questionnaire, full examination of the skin, digital rectal examination, proctoscopy, sigmoidoscopy and patch testing. Patients were treated according to clinical findings at assessment. RESULTS: Thirty-four patients had a recognizable dermatosis, three had superficial perianal fissuring and three had a normal perineum; two required surgical intervention. Eighteen patients had a positive reaction when patch tested. All patients have shown an improvement or complete resolution of symptoms with treatment. CONCLUSION: This series has shown that the majority of patients presenting with pruritus ani have a dermatosis as the underlying cause of their symptoms and that many of them have developed contact sensitivities to the various topical medications used. These findings suggest that referral to a dermatologist in the first instance may be more appropriate.

The use of laparoscopy in a case of appendiceal cystadenoma presenting as pseudomyxoma peritonei in an inguinal hernial sac.

A case is reported of a patient with a benign appendiceal neoplasm presenting incidentally with mucin in an inguinal hernial sac. Only one such case of a benign tumour, and one such case of cystadenocarcinoma, have previously been reported. In neither of these cases was laparoscopy used in diagnosis or staging of the disease. We review the management of such cases in light of recent proposed changes to pathological classification.

Vaginal melanoma: a current review.

Vaginal melanoma is rare, accounting for less than 3% of primary vaginal tumours. It principally affects postmenopausal women, however no risk factors have been identified. Patients frequently present with vaginal bleeding, but the tumour is locally advanced at presentation. Surgery is only the potential cure. The relative merits of radical surgery-vaginectomy and iliac or inguinal lymphadenectomy-versus wide local excision with prompt treatment of recurrences remains uncertain. High dose external radiotherapy and regional chemotherapy trials have been encouraging, although there is no definite survival advantage. Patients should be offered excisional therapy with the opportunity to participate in trials of adjuvant therapy. Prognosis is poor with a five-year survival of 5-21%. Effective screening measures are required enabling earlier diagnosis.

Short-term low dose intracoronary diltiazem administered at the onset of reperfusion reduces myocardial infarct size.

BACKGROUND: Currently, controversy exists regarding the use of calcium-channel blockers in the treatment of acute myocardial infarction (AMI), due to apparent conflicting results from clinical trials and animal models. One hypothesis to explain such a discrepancy proposes that the timing and duration of drug administration might influence its cardioprotective effect. Pretreatment with calcium-channel blockers or their administration during coronary artery occlusion is associated with the diminished infarct size in animal models. While verapamil failed to reduce infarct size when the drug was given at the onset of reperfusion, similar effects of low dose diltiazem are not known. METHODS AND RESULTS: This experiment evaluated the effect of intracoronary short term low dose diltiazem administration given immediately with postischemic myocardial reperfusion. Yorkshire swine underwent thoracotomy and 50 min of left anterior descending (LAD) occlusion, followed by 3 h of reperfusion. In the first group, diltiazem (2.5 mg diluted in 60 cc saline) was infused into the LAD over 12 min, beginning with the onset of reperfusion (n=8). In the second group, animals received saline instead of diltiazem and served as controls (n=6). Infarct size was 0.13+/-0.06 g/kg of body weight for diltiazem group, and 0.42+/-0.04 g/kg for controls (P=0.01). CONCLUSIONS: Short-term low dose diltiazem delivered exclusively during early reperfusion can significantly diminish infarct size in swine. Local intracoronary diltiazem may be valuable adjunct in patients subject to myocardial ischemia/reperfusion during coronary artery bypass grafting, primary angioplasty for AMI, or thrombolysis for AMI if given immediately after restoration of coronary blood flow.

Perforated diverticulitis following extra-abdominal surgery.

The peritonitis of perforated diverticular disease is a life-threatening condition. We report three cases where it occurred following unrelated extra-abdominal surgery and where surgical intervention proved to be the correct course of management. All cases were treated with a Hartmann's procedure; this is probably the safest option for purulent peritonitis in patients who are a high operative risk and have recently undergone major surgery.

Evaluation of surgery for perianal Crohn's fistulas.

PURPOSE: This study was designed to evaluate the operative treatments performed on patients with perianal Crohn's disease at a tertiary referral colorectal university hospital and to determine the efficacy of management by assessing patient satisfaction. METHODS: A retrospective survey included 59 patients with perianal Crohn's disease who had undergone surgery during the period of 1991 to 1993, inclusive. RESULTS: Twenty-seven patients were treated by laying the fistula open (81 percent successful), and another 27 cases were treated with a loose seton (85 percent successful). Five cases were complicated fistulas and underwent diversionary stomas as part of a primary procedure. Overall success rate, as judged by patient satisfaction, was 83 percent. CONCLUSION: Conservative surgery has a role in management of perianal Crohn's disease. Patient satisfaction can be achieved without complete healing. Better preoperative assessment may improve results further.