A case of solitary kidney with duplex collecting systems and renal vascular variants in an adult male cadaver.

We describe a unique solitary kidney with duplex collecting system and vascular variation observed in an 86-year-old white male formaldehyde- and phenol-fixed cadaver during routine academic dissection. The left renal fossa was empty with an intact adrenal gland, and the right renal fossa contained a fused renal mass with apparent polarity between the superior and inferior regions and two renal pelves converging into a single ureter. There were three right renal arteries supplying the renal mass; the superior and middle arteries were noted to be postcaval and the inferior artery was precaval. There were also two right renal veins draining into the inferior vena cava and following a regional distribution with the superior vein draining the inferior portion of the renal mass. Despite generally being asymptomatic, the detection of renal anatomical variants is clinically important for appropriate patient management and surgical interventions.

The quality of e-fit notes issued in secondary care.

BACKGROUND: Few data are available on the pattern of use of fit notes issued in secondary care settings. AIMS: To evaluate the pattern and quality of e-fit notes issued in an NHS Trust. METHODS: Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes. RESULTS: A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients. CONCLUSIONS: Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

Combined endoscopic stent insertion in malignant biliary and duodenal obstruction.

BACKGROUND AND STUDY AIMS: Self-expandable metal stents (SEMS) are an effective palliative treatment for malignant biliary and duodenal strictures. Combined biliary and duodenal stenting remains a technical challenge, however. The aim of this study was to evaluate the technical feasibility of an endoscopic approach to double stenting of malignant biliary and duodenal strictures. PATIENTS AND METHODS: Consecutive patients referred for palliative gastroduodenal and biliary stenting were followed up prospectively. Patients' demographic characteristics, the site and nature of the strictures, success rates, complications, and survival time were recorded. RESULTS: A total of 64 patients underwent double stenting. In 46 patients, biliary obstruction occurred before the onset of duodenal obstruction (by a median of 107 days) (group 1); in 14 patients, biliary obstruction occurred concurrently with duodenal obstruction (group 2); and in four patients the duodenal obstruction preceded the biliary obstruction (by a median of 121 days) (group 3). The duodenal strictures were proximal to the papilla in 31 patients, adjacent to the papilla in 25 patients and distal to the papilla in eight patients. The majority of biliary strictures were in the middle or distal third of the bile duct (in 52/64 patients). Duodenal SEMS were successfully deployed in all patients. Combined endoscopic stenting was successful in 100% of patients in group 1, 86% of patients in group 2, and in 100% of patients in group 3. Taking the three groups together, early complications occurred in 6% of patients and late complications occurred in 16% of patients. The overall median survival after combined stenting was 81 days (range 2-447 days). CONCLUSIONS: Combined endoscopic biliary and duodenal SEMS insertion is safe and effective for palliation in malignant biliary and duodenal obstruction. Biliary stenting through the mesh of the duodenal SEMS is technically feasible and has a high success rate.

Nonendoscopic transnasal placement of a wireless capsule for esophageal pH monitoring: feasibility, safety, and efficacy of a manometry-guided procedure.

BACKGROUND AND STUDY AIMS: The aim of the study was to evaluate the safety, feasibility, and efficacy of transnasal placement of the Medtronic Bravo capsule for wireless esophageal pH monitoring. PATIENTS AND METHODS: Forty patients with symptomatic gastroesophageal reflux disease were prospectively evaluated. All patients underwent upper gastrointestinal endoscopy and esophageal manometry. The Bravo capsule was then introduced transnasally and released 5 cm above the upper margin of the lower esophageal sphincter. Serial radiographs were performed weekly until capsule release. RESULTS: Of the 40 patients who were evaluated, 38 (95 %) were eligible to undergo the procedure. Transnasal placement proved impossible in one patient (2.5 %). Overall, a total of 39 procedures were performed in 38 patients (the procedure was repeated in one patient because of accidental intragastric fixation). Esophageal placement was successful in 36/39 procedures (92.3 %). The mean duration of the procedure was 10 minutes (range 5 - 16 minutes). Adverse events were noted in five of the 39 procedures (12.8 %), mild epistaxis in two patients (5.1 %) and pharyngeal irritation in three patients (7.7 %). After the procedure, a slight "foreign body" sensation was reported by 20 of the 36 patients (55.5 %) who had undergone successful esophageal placement; two patients (5.5 %) experienced severe retrosternal pain necessitating endoscopic removal of the capsule. At the end of the study, 34 of the 38 patients (89.5 %) stated that they would be willing to undergo the test again if necessary. CONCLUSIONS: Transnasal placement of the Bravo pH capsule is safe, well tolerated, does not require sedation, and avoids endoscopy and its complications.

Spontaneous onset corneoscleral hematic cyst.

Corneoscleral cysts are a rare entity. We report a case of spontaneous corneoscleral hematic cyst, which was treated by cyst excision and lamellar corneal patch graft. No recurrence of cyst was noticed during the 6 years of followup.

The outcome of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study.

BACKGROUND AND STUDY AIM: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital. PATIENTS AND METHODS: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study. RESULTS: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % ( P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death. CONCLUSIONS: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.

Effect of real-time magnetic endoscope imaging on the teaching and acquisition of colonoscopy skills: results from a single trainee.

BACKGROUND AND STUDY AIMS: Most trainees have little concept of the loops that occur during colonoscopy, and have difficulty in appreciating the combination of withdrawal and torquing manoeuvres that are essential to achieving complete colonoscopy. Real-time magnetic endoscope imaging (MEI) allows visualization of shaft looping, and so makes intuitive the manoeuvres necessary to straighten the colonoscope shaft. PATIENTS AND METHODS: Consecutive routine colonoscopies were performed by a single trainee (with previous experience of 15 colonoscopies). Procedures were randomly assigned to be carried out either with the trainee viewing the MEI display, or without the MEI view, which was recorded throughout all examinations. RESULTS: In total, 71 procedures were performed. To assess the trend for learning, procedures were analysed in blocks of 24 consecutive examinations (periods 1 to 3). In the first 24 procedures (period 1), the number of attempts at straightening the colonoscope and duration of looping were significantly less, and the intubation time was shorter, for examinations performed with the MEI view. In periods 2 to 3, there was a continued trend towards improved performance, but without a significant difference between procedures performed with or without MEI. CONCLUSIONS: During training, real-time colonoscope imaging using MEI appears to enhance the endoscopist's appreciation of looping and improves the learning of the manoeuvres required to straighten the colonoscope shaft. A prospective, multicentre study assessing a larger number of trainees is needed to clarify these findings.

Magnetic endoscope imaging: a new technique for localizing colonic lesions.

BACKGROUND AND STUDY AIMS: The precise localization of advanced colorectal lesions preoperatively directs the appropriate surgical management. The use of internal landmarks at colonoscopy can be inaccurate, and other methods are therefore necessary to localize lesions precisely. Magnetic endoscope imaging (MEI), a real-time, nonradiographic technique for imaging of the colonoscope, may assist in determining the location of lesions found at colonoscopy. PATIENTS AND METHODS: A prospective study was carried out to determine the accuracy of MEI for localizing the colonoscope tip anatomically. The MEI system was used to identify one of four predetermined locations within the colon. Once identified, two endoscopic marking clips were attached to the colonic mucosa, and 400 - 500 ml of Urografin radiographic contrast medium was injected to produce an air-contrast "enema." The clips were subsequently localized using plain abdominal radiography, assessed by a single experienced radiologist who was blinded to the colonoscopic findings. RESULTS: Twenty-nine consecutive patients were enrolled in the study. The overall accuracy of MEI in comparison with the air-contrast "enema" was 90 % (26 of 29 cases). There were three slight errors of localization - clips localized to the descending rather than the sigmoid-descending colon junction (n = 1), or to either side of the mid-transverse (n = 1) and hepatic flexure (n = 1) - but these were not considered to be of surgical or clinical importance. CONCLUSIONS: MEI is a reliable and accurate method for determining the anatomical position of the endoscope tip during colonoscopy. When it becomes commercially available, we believe the use of MEI will avoid the need for unnecessary barium enemas for localization of lesions prior to definitive surgery.

Endoscopic resection of large sessile colonic polyps by specialist and non-specialist endoscopists.

BACKGROUND: Patients with large sessile colonic polyps for which endoscopic resection might be feasible are often referred directly for operation. The aim of this study was to determine the outcome of patients with such polyps diagnosed by specialist and non-specialist colonoscopists. METHODS: Patients with large (greater than 2 cm) sessile polyps detected at colonoscopy from January 1995 to July 2000 were identified. Resection technique and clinical and endoscopic outcomes were recorded. Two of the colonoscopists (B.P.S., C.B.W.) are recognized as specialists. RESULTS: Some 130 polyps were identified, 100 detected by either of two specialist endoscopists (including 14 cancers) and 30 by 14 non-specialist endoscopists (including ten cancers). Endoscopic resection of benign polyps was attempted by experts in 80 (93 per cent) of 86 cases and by non-experts in 15 of 20 cases (P = 0.03), with successful management by endoscopy alone in 61 (76 per cent) of 80 and in six of 15 cases respectively (P = 0.01). Complications occurred following three polypectomies performed by an expert (bleeding, two; pain, one) and one by a non-expert (bleeding). The estimated end-cost of management by specialists was less than half of that by non-specialists. CONCLUSION: Endoscopic resection of large sessile colonic polyps is feasible in the majority of patients and should be considered as first-line therapy. Prompt referral to a specialist endoscopist may improve outcomes by avoiding operation or enabling complete excision at a single endoscopy session.

Patient pain during colonoscopy: an analysis using real-time magnetic endoscope imaging.

BACKGROUND AND STUDY AIMS: Colonoscopy is generally perceived as being a painful procedure. Contributory factors are: stretching of the colonic wall and mesenteric attachments from looping of the instrument shaft, overinsufflation, the degree of torque or force applied to the colonoscope shaft, and patient pain threshold. The aim of this study was to determine the frequency of pain episodes experienced during diagnostic colonoscopy and the corresponding colonoscope configuration, utilizing real-time magnetic endoscope imaging (MEI). PATIENTS AND METHODS: Consecutive outpatients undergoing colonoscopy were studied. Patients with previous colonic resections were excluded. Procedures were commenced with antispasmodics only, and patient sedation was self-administered whenever significant discomfort was experienced, using a patient-controlled analgesia (PCA) syringe pump. All "demands" were correlated with the MEI record, which was subsequently analysed. RESULTS: A total of 650 demands were recorded in 102 patients. Seventy-seven percent of all demands occurred with the colonoscope tip in the sigmoid colon, 7 % in the descending colon, 6 % at the splenic flexure, 5 % in the transverse colon, and 4 % in the proximal colon. Ninety percent of all pain episodes coincided with either looping (79 %) or straightening of the colonoscope shaft (11 %); presumed overinsufflation being an infrequent cause of pain (9 %). Of the loops encountered during colonoscopy, the N-sigmoid spiral loop was associated with the majority of pain episodes (56 %). Looping was both more frequent ( P = 0.0002) and less well tolerated in women than in men ( P = 0.0140). CONCLUSIONS: This study is the first to document pain at colonoscopy accurately. Looping, particularly in the variable anatomy of the sigmoid colon, is the major cause of pain, especially in women. Use of MEI may improve pain control by facilitating the straightening of loops within the sigmoid colon, and by enabling the endoscopist to target patient analgesia.

Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial.

BACKGROUND: Colonoscopy can be technically challenging because of unpredictable colonoscope looping. Without imaging, straightening the colonoscope is sometimes difficult since the endoscopist has to guess where the tip is. Magnetic endoscope imaging (MEI), a new non-radiographical technique for picturing the colonoscope shaft in real time, could facilitate loop straightening and thus improve performance. METHODS: We assessed trainees and endoscopists with much experience of routine outpatient colonoscopy. In group 1, trainees examined 113 consecutive patients. MEI views were recorded in all examinations, but procedures were randomised to be done by two trainees, either with the endoscopist and endoscopy assistants viewing the imager display (n=58), or without the imager view (n=55). In group 2, two skilled endoscopists were randomised (as with group 1) to undertake consecutive examinations (n=183) either with (n=92) or without (n=91) the MEI view. MEI views of all procedures were analysed retrospectively. FINDINGS: In both groups, intubation times were shorter (median 11.8 min [4.3-31.5] vs 15.3 min [4-67] [group 1]; 8.0 min [2.6-40.8] vs 9.3 min [2.5-52.6] [group 2]) and number of attempts at straightening the colonoscope fewer (median 5 [0-20] vs 12 [0-57] [group 1]; 7 [0-55] vs 10 [0-80] [group 2]), when the endoscopist was able to see the imager view. In group 1, colonoscopy completion rates were also higher (100% [58] vs 89% [49]) and duration of looping was reduced (median 3 min [0-18.8] vs 5.4 min [0-44.5]) when the imager could be seen. Abdominal hand pressure was more effective when the endoscopist and endoscopy assistant could see the imager view. INTERPRETATION: MEI significantly improves performance of colonoscopy, particularly when used by trainees, or by experts in technically difficult cases; loops were straightened or controlled effectively, resulting in quick intubation times and high completion rates.

Magnetic imaging of colonoscopy: an audit of looping, accuracy and ancillary maneuvers.

BACKGROUND: Colonoscopy is one of the most frequently performed outpatient examinations. However, the procedure is still technically challenging, largely due to unpredictable looping during insertion. The aims of this study were (1) to assess the frequency of loop formation and types of loop during colonoscopy, (2) to determine the accuracy of the endoscopist's assessment of the anatomic location of the endoscope tip and of the presence and type of endoscope loop formation, and (3) to determine the efficacy of abdominal compression and change in patient position in promoting colonoscope advancement. METHODS: Consecutive patients undergoing routine, day-case colonoscopy were studied using real-time, three-dimensional magnetic endoscope imaging. All examinations were performed by expert colonoscopists, blinded to the imager view. The endoscopist estimated the position of the colonoscope tip, assessed when and what type of loop had formed, and the efficacy of ancillary maneuvers such as hand pressure or patient position change. The magnetic imager view of each procedure was recorded and retrospectively analyzed. RESULTS: One hundred complete colonoscopies were performed. Looping occurred in 91% with N-sigmoid (79%) and deep transverse (34%) being most common. Most loops (69%) were incorrectly diagnosed by the endoscopist. Atypical loops were more common in women than men (p = 0.025). The endoscopist's assessment of tip location was correct 85% of the time overall, but 100% in the cecum. Abdominal pressure was less effective (54 of 145 times, 37%) than patient position change (95 of 144 times, 66%) in promoting endoscope tip advancement. CONCLUSIONS: Looping occurs frequently during routine colonoscopy. Although the endoscopist's assessment of tip location is fairly accurate, the majority of colonoscope loops are incorrectly appreciated. Although used frequently, ancillary maneuvers (abdominal compression and patient position change) are effective in only 52% of attempts.

A new variable stiffness colonoscope makes colonoscopy easier: a randomised controlled trial.

BACKGROUND: Colonoscopy remains technically difficult in 10-20% of procedures due to variable colonic anatomy and fixation. The ability to vary endoscope shaft flexibility may help insertion to the caecum. METHODS: Consecutive patients attending for day case colonoscopy were randomised to examination with either the conventional Olympus CF200HL (200HL) or a new variable stiffness (VS) colonoscope. Intubation time, use of stiffening function, and patient pain scores were compared. RESULTS: Of 100 cases, 43 were performed with the 200HL and 57 with the VS. Four incomplete examinations occurred with the 200HL (two sigmoid fixations, two benign strictures) and two with the VS (one obstructing cancer, one fixed sigmoid). Changing to the paediatric scope was successful in all but one patient from each group (obstructive lesions). Stiff mode was applied 23 times in 18 patients and was effective in 15 of these. Intubation time was quicker with the VS (median 6 minutes 32 seconds) than with the 200HL (median 10 minutes 35 seconds) (p = 0.0005). Pain scores were less with the VS (median 7) than with the 200HL (median 24) (p = 0.0081). CONCLUSIONS: The variable stiffness colonoscope combines paediatric shaft characteristics with the ability to stiffen when needed. This instrument significantly reduces intubation time and patient discomfort. Further comparisons should be made with the newest colonoscopes which are less stiff.

Glycoprotein electrophoretic pattern in sera of patients with oral precancerous conditions and upper aerodigestive tract cancer.

Cancer of the upper aerodigestive tract is one of the leading sites of human malignancies in India. Various glycoproteins have been claimed to be specifically associated with cancer. Serum glycoprotein electrophoresis was carried out in sera obtained from 23 healthy individuals [10 without habit of tobacco consumption (NHT) 13 with habit of tobacco consumption (WHT)], 46 patients with oral precancerous conditions (OPC) and 110 untreated patients with upper aerodigestive tract cancer. Eighty-six samples from the cancer patients were also collected after initiation of anticancer therapy. The albumin, alpha, beta and gamma region glycoproteins were quantitated by densitometric scanning after separation by polyacrylamide disc gel (PADG) electrophoresis. Mean values of albumin and alpha region glycoproteins were significantly lower in WHT and patients with OPC as compared to NHT. The gamma region glycoproteins were significantly elevated in WHT, patients with OPC and untreated cancer patients as compared to the NHT. The albumin region glycoproteins were significantly low, whereas, gamma region glycoproteins were significantly elevated in nonresponders as compared to their pretreatment levels. The glycoprotein values in complete responders were comparable with NHT. An extra glycoprotein band was found in the post beta region, in most of the individuals (>50%) with habit of tobacco consumption in all the groups. There was a decrease in the albumin/gamma, alpha/gamma and beta/gamma values in patients with OPC as well as untreated cancer patients as compared to NHT. Albumin/gamma, alpha/gamma and beta/gamma values were lower in nonresponders as compared to their pretreatment value. The results indicate that the alterations in glycoprotein electrophoresis pattern may be useful for early detection of cancer of the upper aerodigestive tract. It may also be helpful in treatment monitoring of cancer patients.

Cheilitis glandularis.

Cheilitis glandularis is reported in two farmers with characteristic clinical and histopathological features. Both patients were treated with vermilionectomy. The prognosis was good.

Operative mortality following surgery for carcinoma of the pancreas.

A series of 85 patients with carcinoma of the pancreas seen in South India has been analysed. The median age was 50 years, 20% of patients being below years of age, and the male to female ratio was 4:1. Diabetes mellitus and smoking were more prevalent among males than in a control group, but this was not the case with alcoholism. Distribution of blood groups was the same as in controls. Clinical features of these patients are reviewed. Operative mortality in jaundiced patients was similar whether simple laparotomy, a biliary bypass procedure or a pancreaticoduodectomy was done. This mortality was related to the depth of jaundice and to the degree of abnormality in serum transaminase levels, but it was not related to the age of the patient, the stage of the disease, ECG evidence of ischaemic heart disease, or abnormalities in either serum albumin concentration or blood urea level. Following biliary bypass procedures 50% of patients were dead within eight months; after pancreatoduodenectomy this interval was increased to 18 months, but differences in the stage of the disease between the two groups would account for the difference in survival to some extent.