Enhancing bowel screening: Preventing colorectal cancer by flexible sigmoidoscopy in New Zealand.

OBJECTIVES: The prevention of colorectal cancer (CRC) attainable from introducing once-in-a-lifetime flexible sigmoidoscopy (FSIG) screening was assessed. STUDY DESIGN: This is a review of relevant available information for the assessment of the impact and resource demands of FSIG in New Zealand. METHODS: The reduction in bowel cancer incidence achievable by one-off FSIG screening from 50 to 59 years of age, an age group for which bowel screening is not currently offered, was reviewed. The prevention of CRC attainable from an offer of screening at 55 years of age in New Zealand was also estimated. The number and cost of the FSIG screening procedures required and referrals for colonoscopies and the savings in treatment were calculated. RESULTS: Annually, about 27,500 FSIG screening procedures would be required if 50% of those turning 55 years of age accepted an offer of once-in-a-lifetime FSIG screening. This would result in three-four-fold fewer people being referred for colonoscopy than in the national 2-yearly faecal immunochemical test (FIT) screening programme and subsequently reduce demand for colonoscopy from a false-positive FIT. The number of CRC cases prevented would increase over 17 years to more than 300 per year by 2033. After 10-15 years of screening, the annual savings in health service costs, primarily from CRC prevented, were sufficient to completely fund the FSIG screening. CONCLUSIONS: Inclusion of FSIG screening in the national bowel screening programme would significantly reduce both the incidence and mortality of CRC in New Zealand, reduce the colonoscopy demand of current bowel screening and reduce long-term health service costs.

Ramstedt's pyloromyotomy--what is the correct incision?

AIM: To retrospectively review Starship's complication rates of the vertical midline incision and transverse right upper quadrant incision in Ramstedt's pyloromyotomy. METHOD: A retrospective chart and operation note review over a seven and a half year period of all infants having a Ramstedt's pyloromyotomy for infantile hypertrophic pyloric stenosis at Auckland Hospital. RESULTS: Of 140 patients there were 117 transverse and 18 midline incisions (with 5 exclusions). No statistically significant differences were found between either group for wound, dehiscence, wound infection or incisional hernia. However, wound dehiscence occurred relatively more often in the midline group (2/18) than in the transverse group (3/117), although this did not reach statistical significance (Fisher exact test p-value = 0.15). CONCLUSIONS: There is no convincing evidence that either incision is better than the other. There is a low number of wound complications occurring at Starship with Ramstedt's operation. Overall results compare favourably with both New Zealand and overseas institutions.

Lap seat belt injuries.

Over a 4 month period, three patients presented acutely to Whangarei Area Hospital after receiving severe abdominal injuries caused directly by lap seat belts. They were involved in road traffic crashes and were all seated in the middle rear seat of the car. The aim of this paper is to alert people to the injuries that can occur from two point lap belts. To this end, the patients and injuries sustained are described and a review of the literature is presented.

An audit of pancreatic pseudocyst management and the role of endoscopic pancreatography.

BACKGROUND: A rational algorithm for the management of symptomatic pancreatic pseudocysts is necessary with the increasing availability of radiological, surgical and endoscopic methods of treatment. METHODS: A retrospective audit of the management and outcome of all patients who presented with symptomatic pancreatic pseudocysts to the Auckland Hospital over a 9-year period (1988-96) was made. RESULTS: There were 44 patients (28 men, 16 women; median age 50; range 18-81) in this series. Initial management was not based on pseudocyst size, duration, location, wall thickness, the patients' symptoms and comorbidity, or the aetiology of pancreatitis. Of the 27 patients who had initial conservative management, 15 pseudocysts (56%) completely resolved. Of the 17 patients who were initially or subsequently treated with percutaneous catheter drainage (PCD), 10 pseudocysts (59%) completely resolved without additional treatment. Of the 13 patients initially or subsequently treated by surgery, all but one completely resolved after the first procedure. Two patients were successfully treated with endoscopic pancreatic stent placement. Complications arose in eight patients treated with PCD (47%) and four patients treated with surgery (31%). There was no mortality. The decision for active treatment was not preceded by delineation of the pancreatic duct by ERCP (endoscopic retrograde cholangiopancreatography) in 60% of patients. CONCLUSIONS: More than one-third of all patients with symptomatic pancreatic pseudocysts can be managed conservatively. Surgery yields excellent results but PCD has a high failure rate in patients with an underlying pancreatic duct stricture. A rational management algorithm is presented, based on pre-intervention ERCP, which should improve patient selection and outcome.

The iliopubic tract: an important anatomical landmark in surgery.

A band of fascial thickening, termed the iliopubic tract, lies on the posterior aspect of the inguinal region and has been described in the surgical literature as playing an important role during herniorraphy. This study was undertaken to examine the gross and microscopic anatomy of the iliopubic tract in 12 cadavers. The results confirmed that the iliopubic tract can be readily identified as a thickening of the transversalis fascia running deep and parallel to the inguinal ligament. It attaches to the superomedial part of the pubic bone medially, but laterally its fibres fan out within the fascia transversalis and fascia iliaca without bony attachment to the iliac spines. In contrast to the inguinal ligament, the histological analysis of the iliopubic tract shows a high elastin to collagen ratio. The functional significance of this structure merits further study, but there is no doubt that it is important in many approaches to inguinal herniorraphy. For this reason it is considered that the iliopubic tract deserves greater emphasis in the anatomy teaching of the inguinal region.