Waiting time to lymph node biopsy is dependent on referral method: don't write, phone!

INTRODUCTION: Patients with lymphadenopathy are commonly referred to general surgeons for diagnostic lymph node biopsy. We were concerned at potential long waits for this service in our hospital and thus wanted to compare the efficiency of written and telephone referral with a view to identifying the optimum care pathway for these patients. PATIENTS AND METHODS: Sixty patients were included in a 2-year retrospective review (excluding referrals associated with breast lumps which were managed separately). Hospital Episode Statistics data were used to analyse notes for the source and method of referral, waiting time to biopsy, clinic attendance and diagnosis. RESULTS: Of referrals, 33% were from haematology and 28% from general practice. Overall, 47% of patients were referred by letter; of these, 64% were seen in clinic before biopsy. Personal referral between clinicians, by direct discussion, e-mail or fax led to a mean wait of 4 days, compared to 51 days when patients were referred by letter. Clinic attendance had no significant bearing on diagnostic accuracy or complication rate. Neoplasia accounted for 43% of diagnoses and infection (including four cases of tuberculosis) for 10%. Of biopsies, 33% showed benign changes, 8% were unrecorded and 5% were incorrect. CONCLUSIONS: In this study, 43% of biopsies revealed malignancy and we advise that lymph node biopsy requests should be managed on a fast-track pathway, expedited by direct personal request. Following this study, we have implemented a fast-track pathway for such patients.

Results of a survey of the role of multidisciplinary team coordinators for colorectal cancer in England and Wales.

OBJECTIVE: Over the last 6 years, multidisciplinary teams (MDTs) have been established and play a key role in organizing the delivery of cancer care in the UK. There are no published data on the roles of their co-coordinators. To seek the views of colorectal multidisciplinary team co-ordinators (MDTCs) on what they do and how they do it. METHOD: Questionnaires were sent to the colorectal MDTC, or equivalent, in all 180 NHS hospital trusts in England and Wales where colorectal cancer surgery is performed. RESULTS: There was a 70% response rate. Seventy-one per cent of trusts now have a dedicated MDTC, whereas in 2002, only 40% had one. MDTCs generally keep their information on databases, but these differ, and are not coordinated with data entry into the national colorectal cancer database of the Association of Coloproctology of Great Britain and Ireland. In only 26 trusts does the MDTC communicate decisions to primary care, and the patients seem almost completely excluded from this process. CONCLUSION: The recently formed national MDTC Forum should grasp the opportunity of coordinating all of this well-intentioned but pluralistic activity to the benefit of patients, primary care and hospital teams. An effective MDTC with a robust database will be the key in achieving cancer waiting time targets with useful audit, thereby improving patient care.

Day-care surgery for pilonidal sinus.

INTRODUCTION: The surgical approach to symptomatic pilonidal sinus is open to debate. Many techniques have been described and no single technique fulfils all the requirements of an ideal treatment. Ambulatory treatment with minimal morbidity and rapid return to activity is desirable. The aim of this work was to study the feasibility of day-care surgery for excision and primary asymmetric closure of symptomatic pilonidal sinus. PATIENTS AND METHODS: All patients referred electively over 2 years were assessed in a single-consultant, colorectal clinic and booked for day-care surgery. All patients had excision and primary asymmetric closure under general anaesthesia in the left lateral position. Whenever possible, they were discharged on the same day according to the day-surgery protocol. Patients were subsequently seen in the out-patient clinic for removal of stitches and were followed up further if there was any wound breakdown. RESULTS: Fifty-one patients were operated on electively for pilonidal sinus over the 2 years. Two patients were excluded as the final diagnosis was not pilonidal sinus. At 4 weeks following operation, 43 (88%) had complete healing and 6 (12%) had dehiscence of the wound. Recurrence rate was 8% (4 patients) for follow-up of 12-38 months. There was no admission from the day-surgery unit and no unplanned re-admissions. The cost for day-care pilonidal sinus surgery was estimated to be 672.00 pounds per patient compared with in-patient cost of 2405.00 pounds. CONCLUSIONS: Excision and primary asymmetric closure for pilonidal sinus is safe and feasible as day-care surgery and is associated with potential cost saving.

Randomized clinical trial of the effectiveness of emergency day surgery against standard inpatient treatment.

BACKGROUND: The aim of this study was to assess the feasibility of treating patients with minor and intermediate general surgical emergency conditions as day cases. METHODS: Emergency referrals for minor and intermediate general surgical conditions were assessed by a surgeon. Those fitting day-case criteria and requiring operation under general anaesthesia were randomized to receive standard inpatient care or day surgery. Patients in the latter group were booked on to day-case lists or gaps on inpatient elective lists for surgery within 48 h. The process was coordinated by an experienced theatre sister. RESULTS: One hundred patients were randomized. There was a reduction in the number of nights spent in hospital in the day-case group (median 0 versus 2 nights; P < 0.001). The median time from diagnosis to treatment was 1 day in both groups, although there was a small but significant delay in the day-case group (P = 0.018). There was no significant difference in postoperative outcome or patient and general practitioner satisfaction. The day-case option had no increased impact on primary care services but was associated with a significant saving of about pound sterlings 150 per patient (P < 0.001). CONCLUSION: Certain general surgical emergencies may be managed as day cases with cost saving but without detriment to patient care.

A study of pre-registration house officers' clinical skills.

BACKGROUND: Little is known about the ability of pre-registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register. OBJECTIVES: To find out whether PRHOs have deficiencies in basic clinical skills and to determine if the PRHOs themselves or their consultants are aware of them. METHOD: All 40 PRHOs at the Chelsea and Westminster and Whittington Hospitals were invited to undertake a 17 station OSCE of basic clinical skills. Each station was marked by one examiner completing an overall global score after completing an itemised checklist. An adequate station performance was the acquisition of a pass/borderline pass grade. Prior to the OSCE, a questionnaire was given to each PRHO asking them to rate their own abilities (on a 5-point scale) in the skills tested. A similar questionnaire was sent to the educational supervisors of each PRHO asking them to rate their house officer's ability in each of the same skills. RESULTS: Twenty-two PRHOs participated. Each PRHO failed to perform adequately a mean of 2.4 OSCE stations (SD 1.8, range 1-8). There were no significant correlations between OSCE performance and either self- or educational supervisor ratings. The supervisor felt unable to give an opinion on PRHO abilities in 18% of the skills assessed. DISCUSSION: This study suggests that PRHOs may have deficiencies in basic clinical skills at the time they enter the medical register. Neither the PRHOs themselves nor their consultants identified these deficiencies. A large regional study with sufficient power is required to explore the generalizability of these concerns in more detail.

Effect of small bowel transplantation, denervation and ischaemia on rat intestinal microflora.

The effects of denervation and warm ischaemia on quantitative and qualitative changes in small intestinal microflora following rat heterotopic small-bowel isotransplantation were assessed. Animals with Thiry-Vella fistula, but without transplants, acted as controls. Thirty and 40-fold increases in bacterial colony counts were seen in the isografts compared to controls at 2 and 7 days, respectively (P < 0.05). Aerobic faecal organisms predominated at 2 and 7 days, but an overgrowth of Flavobacterium meningosepticum occurred at 28 days in the transplanted and host bowels. The effect of warm ischaemia on intestinal microflora was assessed by the application of a microvascular clamp to the superior mesenteric artery for 90 min. The effect of denervation was assessed following microsurgical division of all nervous tissue around the superior mesenteric artery. After 7 days, lengths of jejunum and ileum were removed and intraluminal microflora assessed. The number of bacterial colonies isolated from the ileum in the warm ischaemia group was six times greater than the number in the control group, whereas no significant changes were seen in the upper bowel. In contrast, denervation led to a slight, but consistent, decrease in colony counts. These findings suggest that the increase in bacterial numbers in an isografted small bowel primarily results from warm ischaemia rather than from mesenteric denervation, and that physical aspects of the procedure may affect the development of sepsis following small-bowel transplantation.

Method for diagnosing rejection in small bowel transplantation.

Diagnosis of rejection in small bowel transplantation by the identification of a host-cell infiltrate is hampered by the physiological trafficking of host lymphocytes to the 'gut-associated lymphoid tissue' of the graft. This study compared physiological host-cell infiltration of small bowel grafts with that occurring in rejection and stable immunosuppression. Physiological host-cell infiltration, where the graft does not present an immune stimulus to the host, was assessed by transplanting bowel from DA to (DA x PVG) F1 hybrid rats. The extent of host-cell infiltration was determined by immunohistochemical analysis. In the lamina propria, considerable infiltration by host cells was seen, although it was significantly less than that in rejection or stable immunosuppression. By contrast, host cells were seen in the intraepithelial compartment only in rejection. Host-cell infiltration in the absence of an allogeneic stimulus suggests that histological identification of host cells in the lamina propria is not necessarily indicative of rejection. However, the presence of host cells in the intraepithelial compartment is specific for rejection in small bowel transplantation.

Potential candidates for small bowel transplantation.

The number of potential candidates for small bowel transplantation in the UK is unknown. Potential recipients are those with irreversible small intestinal failure, including those treated with permanent parenteral nutrition. This study of one of the largest groups of patients receiving such nutrition identified ten of 25 adult patients as possible recipients. The remaining 15 were considered unsuitable, mainly because of multiple previous abdominal operations or abscesses. Extrapolation of these data to national figures on the incidence of irreversible small intestinal failure suggests that each year up to 20 new adult patients in the UK might benefit from small bowel transplantation.

Small bowel transplantation: future prospects.

The mesenteric lymph nodes and Peyer's patches of the small bowel present a significant target for immune attack in rejection. In addition they have the potential to proliferate and cause graft-versus-host disease (GVHD). Immune-mediated impairment of mucosal barrier function will allow translocation of bacteria from the gut lumen into the blood stream. This factor, with the development of septicaemia, was probably responsible for the majority of deaths in early clinical cases treated with azathioprine and prednisolone. In the experimental situation GVHD and rejection can be studied as separate entities in transplants between parental strain rats and F1 hybrids. The use of immunohistochemical staining with strain specific monoclonal antibodies has enabled the migration pattern of lymphocytes to be studied. Within 24 h of transplantation donor lymphocytes can be detected in the spleen and mesenteric lymph nodes of the recipient. This cell transfer is clearly effected through the blood stream as the severed lymphatics of the grafted bowel take at least 7-10 days to regenerate and from connections with the recipient lymph system. At a practical level impairment of normal lymphatic drainage may cause problems with the absorption of fats and fat-soluble molecules such as cyclosporin. Denervation of the bowel also presents a problem in the initial phase after transplantation, with hypersecretion from the crypts causing diarrhoea. Since the introduction of cyclosporin a small number of successful human transplants have been reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Major trauma: a district general hospital experience.

A retrospective review of all patients with major trauma admitted to a busy suburban district hospital was conducted over a 1-year period. Outcome for each patient was assessed using the TRISS system which calculates the probability of survival based on anatomical extent of injury and degree of physiological disturbance at the time of admission. Thirty-nine patients were admitted following major trauma, of whom nine died. Seven of the deaths were in patients with a greater than 50 per cent chance of survival according to the TRISS system. In contrast, four patients survived who had a greater than 50 per cent chance of death. Details of these 11 cases are given. The numbers of patients who were referred to neurosurgeons and cardiothoracic surgeons in regional specialist centres were recorded, as was the relative contribution of general and orthopaedic surgeons in our own hospital. We conclude that, in the absence of specialized trauma centres, a reasonable standard of care for patients who have sustained major trauma can be delivered in a district general hospital.