Colonic stenting in acute malignant large bowel obstruction: audit of efficacy and safety in a Singapore tertiary referral centre

INTRODUCTION@#Acute malignant large bowel obstruction (MBO) occurs in 8%-15% of colorectal cancer patients. Self-expandable metal stents (SEMS) have progressed from a palliative modality to use as bridge to surgery (BTS). We aimed to assess the safety and efficacy of SEMS for MBO in our institution.@*METHODS@#The data of patients undergoing SEMS insertion for MBO were reviewed. Technical success was defined as successful SEMS deployment across tumour without complications. Clinical success was defined as colonic decompression without requiring further surgical intervention. Rates of complications, median time to surgery, types of surgery and rates of recurrence were studied.@*RESULTS@#Seventy-nine patients underwent emergent SEMS placement from September 2013 to February 2020. Their mean age was 68.8 ± 13.8 years and 43 (54%) patients were male. Mean tumour length was 4.2 cm ± 2.2 cm; 89.9% of malignant strictures were located distal to the splenic flexure. Technical and clinical success was 94.9% and 98.7%, respectively. Perforation occurred in 5.1% of patients, with none having stent migration or bleeding. Fifty (63.3%) patients underwent SEMS insertion as BTS. Median time to surgery was 20 (range 6-57) days. Most (82%) patients underwent minimally invasive surgery. Primary anastomosis rate was 98%. Thirty-nine patients had follow-up beyond 1-year posttreatment (median 34 months). Local recurrence and distant metastasis were observed in 4 (10.3%) and 5 (12.8%) patients, respectively.@*CONCLUSION@#Insertion of SEMS for acute MBO has high success rates and a good safety profile. Most patients in this audit underwent minimally invasive surgery and primary anastomosis after successful BTS.

Can venous base excess replace arterial base excess as a marker of early shock and a predictor of survival in trauma?

<p><b>INTRODUCTION</b>Arterial base excess is an established marker of shock and predictor of survival in trauma patients. However, venous blood is more quickly and easily obtained. This study aimed to determine if venous base excess could replace arterial base excess as a marker in trauma patients at presentation and if venous base excess is predictive of survival at 24 hours and one week.</p><p><b>METHODS</b>This was a prospective study of 394 trauma patients presenting to the emergency department of a tertiary hospital over a 17-month period. Data on base excess at presentation, vital signs, shock index (SI), injury severity score (ISS), and mortality at 24 hours and one week was collected and analysed.</p><p><b>RESULTS</b>Arterial and venous blood gas tests were performed on 260 and 134 patients, respectively. Patients were stratified into groups based on their SI and ISS for analysis. There was no statistical difference between mean venous blood gas and arterial blood gas levels at presentation when SI > 0.7, regardless of ISS (p > 0.05). The mortality rate was 4.57%. Both venous and arterial base excess was lower in nonsurvivors compared to survivors (p < 0.05). However, at 24 hours and one week, the difference in base excess values at presentation between survivors and nonsurvivors was greater when using venous base excess compared to arterial base excess (11.53 vs. 4.28 and 11.41 vs. 2.66, respectively).</p><p><b>CONCLUSION</b>In conclusion, venous base excess can replace arterial base excess in trauma patients as a means of identifying and prognosticating early shock.</p>

The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better?

<p><b>INTRODUCTION</b>Massive transfusion protocol (MTP) is increasingly used in civilian trauma cases to achieve better haemostatic resuscitation in patients requiring massive blood transfusions (MTs), with improved survival outcomes. However, in non-trauma patients, evidence for MTP is lacking. This study aims to assess the outcomes of a newly established MTP in a civilian setting, for both trauma and non-trauma patients, in an acute surgical care unit.</p><p><b>METHODS</b>A retrospective cohort analysis was performed on 46 patients for whom MTP was activated in Changi General Hospital, Singapore. The patients were categorised into trauma and non-trauma groups. Assessment of Blood Consumption (ABC) score was used to identify MTP trauma patients and analyse over-activation rates.</p><p><b>RESULTS</b>Only 39.1% of all cases with MTP activation eventually received MTs; 39.8% of the MTs were for non-trauma patients. Mean fresh frozen plasma to packed red blood cells (pRBC) ratio achieved with MTP was 0.741, while mean platelet to pRBC ratio was 0.213. The 24-hour mortality rate for all patients who received an MT upon MTP activation was 33.3% (trauma vs. non-trauma group: 45.5% vs. 14.3%). The ABC scoring system used for trauma patients had a sensitivity and specificity of 81.8% and 41.2%, respectively.</p><p><b>CONCLUSION</b>MTP may be used for both trauma and non-trauma patients in acute care surgery. Scoring systems to predict the need for an MT, improved compliance to predefined transfusion ratios and regular reviews of the MTP are necessary to optimise MTPs and to improve the outcomes of patients receiving MTs.</p>

An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device

<p><b>INTRODUCTION</b>Intraosseous access is an alternative to conventional intravenous access when access is difficult or impossible in the adult population. The EZ-IO is a novel intraosseous access device designed for use in adults, utilising a powered driver.</p><p><b>MATERIALS AND METHODS</b>A prospective, observational study involving a convenience sample of 25 medical students, physicians and nursing staff recruited as study subjects to secure intraosseous access using the EZIO powered drill device, on a bone model.</p><p><b>RESULTS</b>Twenty-three (92%) of the 25 study subjects required only 1 attempt at placing the EZ-IO. There were 24 (96%) successful placements of the EZ-IO. The average time taken to place the EZ-IO was 13.9 seconds. Twenty (87%) of 23 participants reported easier placement with the EZ-IO than an intravenous cannula. The average time taken for the physicians, nursing staff and medical students was 3.71 (+/- SD 1.70) seconds, 7.88 (+/- SD 4.02) seconds and 33.7 (24.5), respectively. Overall mean difficulty of insertion score (VAS) was 3.1 (+/- SD 1.9).</p><p><b>CONCLUSION</b>The intraosseous access device evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential for use in the Emergency Department.</p>

Managing breast cancer diagnosed in first trimester pregnancy: a case report

<p><b>INTRODUCTION</b>Breast cancer is the most common malignancy in pregnant women, occurring at a rate of about 1 in 3000 pregnancies. Unfortunately, this will sometimes occur during the first trimester of pregnancy and this situation warrants discussion of management options with regard to the mother and child, especially with the current trend of deferring child bearing to a later age.</p><p><b>CLINICAL PICTURE</b>We present a 34-year-old primigravida who had a breast lump prior to confirmation of her pregnancy and received her diagnosis of invasive breast cancer at 7 weeks' amenorrhoea. The oncologic management options of this pregnant patient with breast cancer are discussed.</p><p><b>TREATMENT</b>The patient eventually opted to undergo wide excision of the breast cancer with sentinel lymph node biopsy and possible axillary clearance together with termination of her pregnancy.</p><p><b>RESULTS</b>The patient successfully underwent surgery for her breast cancer and was subsequently treated with adjuvant therapy as per normal protocol for a non-pregnant patient.</p><p><b>CONCLUSION</b>The management of breast cancer and pregnancy occurring concurrently is a complex problem fraught with many dilemmas for both the medical team, the patient and her family. The option chosen must involve a multidisciplinary team and have full informed consent of the patient.</p>