Risk factors and diagnostic criteria for colorectal anastomotic leaks

Background: Anastomotic leakage [AL] after colorectal resection and anastomosis is a major complication with significant morbidity and mortality

Objective: To identify the risk factors for AL and to identify a standardized diagnostic protocol to reduce delay in diagnosis of AL

Design: A Systematic Review

Setting: King Hamad University Hospital, Bahrain

Method: A Systematic Review of English-language studies was performed. An internet search of full-text articles in three different databases: The Cochrane Library [Controlled Trials Register], Medline [PubMed] and EMBASE from 1990 onwards were reviewed

Result: Literature review has produced a varying AL rate of 2% to 22%. The major risk factors isolated were advanced age [>65 years], multiple comorbidities/higher ASA grade, low preoperative serum albumin level, steroid use, longer duration of surgery and contamination of operative field. Delay in diagnosing AL was reduced by use of standardized surveillance protocols postoperatively

Conclusion: Preoperative risk stratification facilitates decision making whether to provide a diverting stoma or not. In addition, a standardized postoperative surveillance decreases delay in the diagnosis of AL, thereby, decreasing morbidity and mortality

Urgent ureteroscopies in acute ureteric colic requiring intervention

Background: Urolithiasis, in general, constitutes a significant volume of the daily clinical activities in our institution

Objective: To evaluate the outcome of ureteroscopies performed in patients admitted acutely with symptomatic ureteric calculi compared with elective ureteroscopies

Design: A retrospective review

Setting: Department of Urology, King Hamad University Hospital, Bahrain

Method: All ureteroscopy [URS] procedures performed for symptomatic ureteric calculi between 1 January 2013 to 31 December 2013 were reviewed. These procedures were divided into two groups: urgent URS and elective URS group. Both groups were comparable in personal and stone characteristics

Result: One hundred ninety-five procedures were performed on 167 patients. One hundred twenty-seven [65.1%] procedures were urgent and 68 [34.9%] were elective. The cohort included 131 males and 36 females with a mean age of 41.5 years, a range of 19 to 74. One hundred fortynine [76.4%] procedures were performed on male patients, while 46 [23.5%] were performed on female patients. The mean stone size for patients undergoing urgent URS was 7.7 mm and 8.3 mm for elective procedures; approximately one-third of patients had more than one stone. Eighty-one stones in the urgent group were distally located; fifty-seven were in the elective group. The most common indication for urgent URS was pain refractory to injectable analgesia. LASER was used in 182 [93.3%] procedures, 179 [91.7%] procedures were urgent. Seventeen [8.7%] complications were documented for urgent URS and 8 [4.1%] for elective cases, no statistical significance, P value = 0.74

Conclusion: Urgent URS procedure is a safe and cost effective option compared with Elective URS. It should be the preferred option when resources and expertise are available

Misunderstanding of the term [DNR] in a middle-eastern teaching hospital

Do-not-resuscitate [DNR] order has been practiced for many years; though it is one of the most commonly misunderstood and misinterpreted orders in medical practice. It has many ethical, legal, geographic, religious and cultural aspects that contribute to this misunderstanding. To assess the perception amongst the acute specialties who deal with DNR orders. A Cross-Sectional Questionnaire Type Study. Setting: King Hamad University Hospital, Bahrain. Anonymous questionnaire was designed. Physicians working in the acute specialties were included. The questionnaire included several general questions about when DNR should be implemented and what are the appropriate aspects of management that should be given. Fifty doctors completed the questionnaire; 49 [98%] of the physicians thought that a hospital should have a DNR policy, 23 [46%] of the physicians believed that the DNR decision lies in the hands of the responsible doctor, 10 [20%] of the participants thought that it is a family decision only, whilst 17 [34%] thought that it is a joint decision by the family and the physician. All of the physicians agreed that there should be no code blue activation in case of cardiopulmonary arrest of a DNR labeled patients. The term DNR should not be used as it is confusing and liable to misunderstanding. In addition, we need to educate healthcare professionals about the terminology of the management of end-of-life situations

Management of a self-inflicted laryngeal injury

We present a case of deliberate self-inflicted trauma to the airway. The patient presented with a slit throat secondary to attempted suicide. The patient had a GCS score of 15 in the emergency department with an ability to maintain his own airway and phonation. A cuffed tracheostomy tube was inserted through the wound to maintain the airway. The patient had full wound exploration and repair of anterior tracheal wall. Repeat laryngoscopy and bronchoscopy was done postoperatively which revealed left vocal cord palsy which recovered completely after 2 weeks